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FOR OFFICE USE APPLICATION FOR SANITATION PERMIT, Permit No. (complete in Triplicate) Date lstued This permit Expires I Year From Dal*Issued Application is hereby mode to the Son Joaquin Local Health District for a permit to constmv and install the workivrein described.This application is made in compliance with County Ordinance No. 549 and existiig Rules and Rzg rss //.� �e �.�,�C.-t-:.�n..� �rl �t'"r'..:,a" CENSUS TRACT -.... .. JOB ADDRIESS/LOCATION . .--- .. .. _. . . Fhone...... ........ .................... Owner's Nome �p _ ......_ _. r Address 3 i 3 - -._._ Conlractor's Nomer-••.•,c ,lw�..w.7c-+-.a.lioansa#/�dr3o. . Phone InstdMion will serve-. Residence&4caknent House❑Commerdiol❑Trailer CoL-rt ❑ Morel❑Other _ ..........'--------- ------ Gor .. ....._ Number of ('wing units, !f Number of bedrooms -.*j;?_.-.-Garbage Grinder lot Size ..... .. -..... Water Supply:Public System and none " .... ..-_.. --— ... -------------_ .................Private Character of soil to a depth of 3 feet. Sand❑ 'It❑ Cloy 11 Peat C] Sandy Loam Cloy Loam 13tfordpon[Adobe❑ F81 Material .... . . .If yes.type..- -- "".-----.----...-.-. (Plot plan, showing size of lot, location of system in relation to wells, buildings. etc. must be plernd on reVarae side.] NEW INSTALLATION: Wo septic tank ar seepage pit permitted If public sewer is available within 200 feet,] PACKAGE TREATMENT I ] SEPTIC TANK[ ] Site.." . ........ .. .. - -- . Liquid Depth ............. ...._. . . . . .- Malaria;_ . No. Compartments ......._......---- V CCP 6:y Type .. . .......... . .. Distance to neamsL Well ... ................Foundation .. _. ... Prop. Line............._..— Total Length ................__...-. ^ LEACHING LINE I I No. of Lines . Length of each fin" - - .K ...............Depth Filter Material .."..-........................_. Di Bar -. Type Filler Notarial P Foundation . . Property Lina -----------_...._..... Distance to neoresh. Well . - .... . . - .. Diameter ... Number Rack Flllod Yes ❑ No Q SEEPAGE PIT ! I Depth -'""' ... __ . . .. . Water TTableDepth - - . .. -...... .............Rock Size., . ............ Distance to iseatesb Well .. ._.. . ..Foundation ._....... Prop. Lim ...... __..... .. . . .. . . REPAIR/ADOHIDNIPtev.Sanitation Permit# ._..... .. ... ... Data ......... ......... ..........I .( Requirements) ...- ...... ...................................�..._....__.... Septic Tank ISPac T' R c'q -.-.. - . Disposal Field (Specify-w .... ........_...-..._/....... C.c�. �..f^s. �C(�w.L-�+-i ��s.. � .�R....:�J,...n-�i,.a.... �:....:�c.�..,L.-.-�..!�...:�:••x..I!=...7F..._.... 33`X Q ........... ...-................ (Draw existing and required addition on reverse side) 1 hereby certify that 1 have Prepared this applic don and Haat the walk will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District.Homo,owner or licon- sod agents sign owm certifses the following: I :hall not emplay any person in such manner -I codify that In the performance of the work for which this permit is issued, as to become subiect to Wetkman's Compensation laws of Califomia:' �� _. Avner S,gned y— �svo^ _. - " 7itle :L< �....C'�c...i�4-Y - ...... ...... By cy _ Ilf outer than owner) a� FOR DEPARTMENT USIE'ONLY APPLICATION ACCEPTED &Y Z,� . .""... " DATE . ---- --6. ----- . . - DATE . .-._. _ ..... .... SL.ILDtN ADDITIO PERMIT ISSUED - .. .. .. ADDITIONAL COMMENTS _.. .. . . .. . .. F,nal In-pe-Con as^ SA%. JOAQUIN LOCAL HEALTH DISTRICT