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FOR OFFICE USE: ................................ APPLICATION >:OIt',SANITATION PERMIT ...........:.:..:...:.:............. .. (complete in Triplicate) Permit No. 5P/ y ................................. This Penult Expires41- .................. 1 Year From Date Issued daM issued •................... Application Is hereby made to the San Joaquin Local Health District for a described. This application is made in compliance with County Ordinance No. 5�l9 and existing Rules and Regulations: permit to construct and Install the work herein JOB A©DRESS/LOCATIQ .---, �G ••--- . ........ Owner. .... .... ........•--• : .CENSUS TRACT s Name ................. .. ...._ ..... ------•--................. Address ,-sa one _..-----•- Contractor's Name .� --• -•---... - - -- • ------------License# Art installation will serve: 12$sidence❑Apartment House Phone ___.._.. ---- ❑ Commercial❑Trailer Court [3 Motel ❑Other.....Ad G/- Number of living units_____________ Number of bedrooms ___:-T-•--Garbage. Grinder ..._.._.:.. Water Supply: Public System and name lot Size Character of - •...... ....... soil too depth ^---------••------•------ -------------------------- am �. p of 3 feet: •--•--- _ ___________ --- ._Private . - Sand[] silt❑ Clay ❑ Peat❑. Sandy Loam 0 -Clay Roam 5!9r_" Hardpan 0 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 see ge pit permitted if public sewer Is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK Size`,��,i►'1 F ..2�..._Jr'. ...... Liquid Depth CapacityType� 7re'st: e � . Material Distance tNo. Compartments ____.3............. o Well ----_---- �-� .--Foundation /e IW Sa ,." ..••----•.............. ...__ Prop. line ..----`�----.�``�' LEACHING LINE ••-----• •---- , .. [ No, of Lines .................."--_-- Length of each Eine'---------••------••-•_----. Total Length ....................... - 'D' Box g ..... Type Filter Material ..........•---------Depth Filter Material ........ . ..... . �[ Distance to nearest: Wel! /A0 -_ foundation ---- Property Line _.. .. - .. '. � Depth _.. { _��i't'.---•.. �f��x.`�zumber ._......� -• '� .-••••--""-- Rock Filled Yes f�' No �] Water Table De x , pth _.. ., v. ---•----- -hock Size .1..�.d_./.��..�.._ . Distance to nearest: Well _......__. m° __--_•__...Foundation .._.lam /� REPAIR/ADDITION(Prev. Sanitation Permit# _•-_____._-_-_____•." -•-_ Prop. Line ...`._� _._- .....• --------------- Date ) Septic Tank ISpecify Requirements) .............. ._----....I...__._---. r .- - 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 San Joaquin County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin local Health:mistrict. Home owner or Ilcew sed agents signature certifies the following: a "I certify that in.the performance of the work for'which this permit is issued, 1 shall not employ an k as .to become subject to Workman's Compensation laws of California." p Y Y person in such manner Signed -•- -- ----- --•" "" ""'-- Owner By ----------- --------- - .._...- Title _ (if other than owned FOR DEPARTMENT USE ONLY APPLICATION,.ACCEPTED BY r i BUILDING PERMIT" ISSUED -------- ""--- - -- - - -- -- a + -------------- -•••-- ..............-------------------------- -•--•---------• - ------- --•--- --•'-•-- --- -------- ------------ -- - -•-----._. .._ •-----•--------_------- -.._._.• __.._...._.._:_...•------••------- ............---... ----------------------- _ _ --- ------------• ---- inol 1 --_._ nspection by: . - -- -- ---- ••--- ---------------••--•---.--•--------....__.._..__..._.._ . .._ .. EH 13 241 1-68 Rev. 5 . _ Date .t�j .y"....._..� --------------- 5AN JOAQUIN LOCAL HEALTH DISTRICT $/7h 3M