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APPLICATION FOR SANITATION PERMIT Permit No. _X Fj (Complete In Triplicate) This Permit Expires IYear From bate Issued pate Issued Application is hereby made to the San ,Joaquin Local Health District for a permit to construct and install the work herein described. T is a 1, ion is made in compliance with County ordinance No. 549 and existing Rules and Regulations: © EJ�fN. _i ....-[�_i .e. ...................CENSUS TRACT .................... RI ..__.., 0 JOB AD SS/LO TI�N P"r�� Phone Owner's Name _._.. - . _ (- ------ Address _..20 Vf(V-----F_-- --------- city . •----• ...............License # ------------------------ Phone .............-----------•----- Contractor's Name _-----�4wJ:^r�f�--------•--�4ment --•---•--• Installation will serve: Residence House 0 Commercial❑Trailer Court ❑ i Motel ❑Other -------------------------------------------- Number of living units:---.-------- Number of bedrooms ------------Garbage Grinder -------------Lot Size / -- Supply: Public System and name ---------------------------•- ------ - ------------------------ ................-Private Water Character of soil to a depth of 3.feet: Sand El Silt❑ Clay ❑ Peat Sandy Loam {/ Clay Loam ❑ Hardpan Q Adobe❑ Fill Material . . _ .-If yes,type ::............. .... (Plot plan, showing size of lot, location of system in relation to we11s, buildings, etc. must be plated on reverse slde.l r� NEW INSTALLATION. (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK I } Size.-. ...� __.. ........•............... Liquid. Depth :......----.•............. . j if Capacity __ Type; �---I,:%; No. Compartments ...� -.-----�..._ i Distance.to nearest: Well .71_-•-............... f ---- Prop, Line..-zS---- ----------- LEACHING LINE [.] No. of Lines --•-- ------------ Length of each fine--------74-------•------ Total Length .._ ........... U D' Box .e _. Type Filter Material - .....Depth Filter Material ... .__ ..._ -----•- /- �_� _ Distance to nearest, Well .._ �_ '�__�.�� Foundation -------- Property Line ...... .. ...... L : D . S I ....................... ...........Ro,k Sipa - - -----.. yDie4nnrR to neerp5f 1N�11 ..._-- -- Fa -..:............: Pi6ii48- -•-.• ._..... REPAIR/ADDITION{Prev. Sanitation Permit+#:E ---•---- - - Date ----------------•----------------1 Septic Tank {Specify itequirementsj.- I . -----------•-•---•... •-••-----••--•------- - _..........--•-•- ._._._...- Disposal Field (specify Requirements) _Ak-` •--�./-V1CR_Pt.---...�'A-NK ........... -----7e9_ x 2 SER �i (Draw existing and required addition on reverse side) ! I hereby certify that l have prepared this application and that the work will be done in accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,District. Home owner or licen- sed agents signature certifies the following: ,I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner i as to become subject to Workman's Compensation laws of California." Signed --------- �;� -----•----------••--------•- - -- Owner -------------------------- ------BY E -------------------- Title -------------- -------------------- ............... ------ ---------- {If other than owner) --i I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - � - �� * L/ �T(.-•------ ---- - - DATE -... _. I :1- ------------- BUILDING PERMIT ISSUED ----- ------ -- --- .....DATE •---------- ------------- k ----- ADDITIONAL COMMENTS --_-- `' -ro ' f P ---------5TK ----`- ----- --------..- ---- ----- - ---- ---------------- ---------- ------ ----- " A ---- --- - --------------- -- - .. - ------- ------------- ---------------- --------------- --------------- ------_Dare .. _ - Final Inspection by: .... r .. / . 7- EH 13 2!i 1-613 u• I SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3M