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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �� 131 (Complete In Triplicate) 4 Permit No. ..................... .............. This Permit Expires 1 Year From Date Issued Hate lssued .a:....... i Application is hereby made to the Son Joaquin Local He District for a permit to construct and install the work herein i described. This application is made in compliance with 4 linty Orc#i nce No. 549 and existing Rules and Regulations: ! JOB ADDRESS/LOCATION ......42.g; CENSUS TRACT ... Owner's Name .._ .. .... . ...... .................................. no ............ ,`�.CJ..®�....... . Address ............ �_._._,....... .. ............ ............City .. ...............--•-•---........... ......------...--•-- Contractor's NameR♦1! ?�` •..•...License # �� pJ7 ............. Phone ................J.7 Installation will serve: Residence Apartment House C) Commercial❑Trailer Court ,❑ Motel ❑Other.. ....................................... .. r Number of living units:.......(.... Number of bedrooms ..:_.Garbag Grinder ..... Lot ize .........4!.A...r.PS...I Water Supply: Public System and name .........................I.........� ..... ./.-� .._. .. .... ..._....:::.---.._.....Private ❑ Character of sail to a depth of 3 feet:F Sand❑ Silt p Clay Peat❑ Sandy Loam ❑ Clay Loam— Hardpan p ,Adobe Fill Material ............ if yes,type ............................ )Plot plan, showing 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 TANK[ ] Size--------------------------------------- ---- Liquid-Depth .................... S Capacity --------i------••-•- Type .................... Material-----•-------- --•••- No. Compartments ......................j Distance.to nearest: Well ....................................Foundation ...................... Prop. Line ........._...... ..... LEACHING LINE I 1 No. of Lines - Length of each line............. .... Total Length ............................. j 'D' Box .... . ._... Type Filter Material ....................Depth Filter Material ............................................ Distance to nearest: Well ....'................... Foundation --------- ........... Property Line ....................... _ I i _ ------_-------- Number .............i.............. Rock Filled Yes : . :. Na . SEEPAGE PIT ( � Depth �] >D .................... Diameter Water Table Depth ...... .. ......................................Rock Size ---••=•-- --••-•.............. Distance to nearest: Well -----•.............................I. Foundation ......._............ Prop. Line ._.... ................ REPAIR/ADDITION IPrev. Sanitation Permit`..... ........ .......•-••--••---......._.._ Date _-_---------:.............._) 40" Septic Tank (Specify Requirements) ........... .... :................................:....................._.... .. .... Disposal Field ISpecify Re uirements) -- - -__ _ -- � x..:............................ ............ ..... -_--.• ------------ XUA — - ........ --- I -- --- --- i Q r , I l .2 --� ..... (Draw sting and required addition on reverse side)' I hereby certify that I have prepared this application and that the work will be done In accordainca with .San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health:District. Home.ew_ ner or licett- sed agents signature certifies t following: 4 "I certify that In the perEor a of the work f which this permit is Issued, I shall not employ any person in such manner as to become su ' ct o W an',kC mpens n laws If alifornia." Signed ---------- -------, --- ----- . .. ... Owner BY --•-• -------------------- - __ Title - -- ----------- ----------------.._...------............-------------- Of other than owner) FOR DEPARTMEN USE ONLY APPLICATION ACCEPTED BY!_.._ . ' - _..'...,DAT1 a',- .�. '? • BUILDING PERMIT ISSUED - ..---------------------- --------------DATE _... ----.._......_............_-._...__.. ADDITIONAL COMMENTS ._-__-- _ 1. _._ ....-.a _ _ .... --------• ---------------------f ----------------------••-•-•---------------------------------- -------------------------- -----•----------------------------- ._....-- ---------------------•-------•------•------------ . Final Inspection b Lor .Date .... _. . ¢�.� 21a 1-6SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M