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U-GR OFFICE LASE APPLICATION FOR SANITATION I' MIT ............ ...................... I: Permit No. (Complete in Triplicate) - ......................... :....--••- This Permit Expires 1 Year From Date IssuedILE CUA py Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compl►a a with C7unOrdinance No 549 and existing !toles and Regulations: JOB ADDRESS/LOCAT N .._�� `- ,..� -•_- ?! .. ..__. .K c�............CENSUS TRACT .......................... �_.Owner's Name --- -z-k---.....-•----------------•-•---•--•,-----•--...... ............... Phone ' Address f _ ,.r... (o C'- ......City _.R�+..... -------------------------------- ......... j� j Contractor's Name .... .. ------------------------------License ........................ Phone .... ....... Installation will serve: Residence[Apartment House Commercial❑Trailer Court ❑ Motel []Other- .. ............. :..... Number of living units:_._ 1_ Number of bedrooms 7J__Garbage Grinder ............ Lot Size ....,lQ ..................... ............... Water Supply: Public System and name -----------•---•.................__----------..-.......__......._..........._...-----...---................Private ' Character of soil to a depth of 3 feet: Sando. Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam a I Hardpan❑ Adobe, Fill Material ............ If yes,type............... ............ (Plot pian, 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 TANKize...T___?',��1___ ..�f�.............. Liquid Depth . ��.------------- Capacity -------------------- Type i ��. Material = L---- No. Compartments --A-............-.. Distance.to nearest: Well ..f _............... ...Foundation -__/0........... Prop. Line _.. ....... .......... LEACHING LINE . No. of Lines ---1................... Length of each line...10.0p.._......... Total Length .........1.O _.`...... !J D' Box ............. Type Filter Material . 41 .Depth .Fid Material .._.� .........................�...# Distance to nearest: Well ._�.�-:--......... f=oundation ........................ Property Line -----�T-4�.....-.... I SEEPAGE PIT Depth .!A:-57r._.. Diameter Z.3.rr.... Number ----I...................... Rock Filled Yes No C] ' Water Table Depth ----�---- �'. *---------------------------Rock Size ................. �«---•- Distance to nearest: Well ........................................Foundation _.................- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ..I............................... SepticTank (Specify Requirements) ......... •-•-•---•........................•----•---....-•-----------••------•--•-•--------•-----------.---...........-...•---..._•----- I i Disposal Field (Specify Requirements) -- - - ...............................------•.. --------- ---------------------------- -----------------------------............................................................................................ (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 Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the Son 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, I shall not employ any person in such manner as to becom subjtect to W r an's Com ensatio laws of alifornia." r- p Signed ---- ---- --•-`-------'- ----2�-?--Yi _ Owrtef- By -- ---- -•- _ �.......... Title ................. . . ........................ (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .-- .............................................................. -'� .......- •.... DATE �..-------- - --- -- --= BUILDING PERMIT ISSUED ...---- .-• -- ...........DATE -..----- •................................ ADDITIONAL COMMENTS ........... .._..... _............. .................... ----•---••--------------- •---------------•----•-I........ ------...------ .....--- ............... ..................... ....----- --•.......................................... _ ... ; Final inspection by: _... _ Date -- .. .-.. -� . .�� EH 13 2h 1-613 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M