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FOR OFFICE USEt APPLICATION FOR SANITATION PERMIT Permit No. �5-:.r-�:�•� .................................................... (Complete In Tdpllcotel C Date issued .................................................. - .. . . - This Permit Expires 1 Year From Doh 4$sued Application Is hereby made to the Seen Joaquin local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulationst TION . ��--. c� .......................I....-CENSUS TRACT .,........................ ,LOB ADDRESS/to .....,..-... ................... — Phone..................................... F Owner's Nome ........................................... ....... i Address . il� 1 -................................. ..City = . a. Contractor's Name 411` e e" .........License 1 �r Phone .............. ............... Installation will serves Residence❑Apartment House Q Commercial oTraller Court -0 Motel ❑Other --- ---- •----••-•--._.... Garbage Grinder Lot Size ................... Number of living units:............ Number of bedrooms g ..__..._.... •---..•, .. Water Supply: Public System and name ... ------- -- .............................Private 0 Character of sall to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam illClay Loam ❑ Hardpan❑ Adobe❑ Fill Material .............If yes,type ............... ........ ... plot plan, showin size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available'within 200 feet,) PACKAGE TREATMENT ] SEPTIC TAMC Size................................................ Liquid Depth .........._......_.:,... 1 Capacity Material...................... No. Compartments ....................= Type -•••........._-•-_.. ...___Foundation ....__ Prop. Line ...............Distance fa nearest: Wel! .....__ ................ Total Length T- LEACHING LINE No. of Lines Length of each line.•.................. ..................... �.. Box -.-._.......'D' ` .Filter Material ....................Depth Filter Material .... --..-..:,,:. Typet � . ........................ :.-.. .L ns ......... '...Foundation _..... PropertyDistance to nearest: Well ....... Number .----- .,-------.. ..... Rock Filled Yes No SEEPAGE PIT Depth .................... Diameter ......... Water Table Depth .... ...........................................Ro;k Size ....... _ Distance to neared: Well ....................Foundation ............... Prop. line ..........~....... J REPAIR/ADDITION(Prev. Sanitation Permit ----------------_........................... Date ........_.......................... ) r Septic 'tank (Specify Requirements) ................. ..... : . . ....... : •- , ........:......:..................... ..._................ .. . ................ Disposal Field (Specify /Requirements) ..... ..On .......................................... --••-••-- t? 1 c `_...�J'r' :... ..... ........... --......_..........:.........,__._............................._...... •- :............ ....... ........ .....................:. .........._..........._._..... _.__........_.......... - .............................. ............... (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local'Health District.Home Owner or Ikon• sed agents signature certifies the following: 4' "I certify that In the performance of the work for which this permit is issued, I shall not employ any person In such manner as to become subject to Workman's Compensation laws of California." I Signed !_... .. Owner 13 ....................................... ta..a--f {:...- �' . Title ......... .............. .__.....__ y (if other than owner) FOR DEPARTMENT USE ONLY DATE APPLIO BUILDING PERMIT ISSUED . .... ................ .�•----........,-...--_.....••---....::-••---••--..._•....: .. ..... DATE - . --•- ....:... .......__.... ................ ADDITIONAL COMMENTS •.. _..---.......................--...-.-...-.-....-..-.-•--------------••---...-.---..........----•--.......................... - --•-- .--............-.....----•.----....... ................... .................. ...... ...... ......... J.......--.. .--.-..------ ------------------ ::::: :.........•-- ..... ......................-. ............Date ... . ..•---....-..- Final inspection by- ---------------------- �'•-•---- -. EH 13 24 1-68 Rev. 5i SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M 1' :r