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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT •...... ........................ � Y i (Complete in Triplicate) Permit No. _.y ......... .........:....................................... I I This Permit Expires 1 Year From Date Issued Date Issued j ,Appli anion is hereby made to the San Joaquin Local Health District for. a permit to construct and install the work herein i�describecl.' This application is made in compliance with County Ordinance No. 549 and existing R les and Regulations: I OB ADDRESS/LOCA � �' ._......, .. ASUS TR ................_..�/ .:_...: kOwner's Name :.... . ..... _.�.-2............................................................. ...... ....!..._..._. shone ..._ .... I ddress ... ...•3.�� .�.. _.......... City .. 7g.it,. p.. Contractor's Name __ .._,_-•-. License # .7/, 3.;1 Pho e . kA.. Installation will serve: Residence partment House] Commercial []Trailer Court ❑ Motel ❑Other -------------------------------- Number of living units:.....l_... Number of bedrooms ..__.Garbage Grinder _/IIv. Lot Size Water Supply: Public System and name .........................•----------- --• ---•-----_---- --- ........... ....Private Character of soil to a depth of 3 feet:Sand _Silt F-11Clay ❑ ' Peat-❑ Sandy loam ❑ Clay Loam Hardpan ❑ Adobe[:] hll M6terial ...f1.A.. 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..... ,)C.S`X_.rJ. j Liquid bepth ... Capacity "`' p ty ..j.Z::...._.... Type 9 £�_S . Material._C.�?,- No. Compartments ._._ '............. Distance to nearest: Well ._........ . �. .......Foundation .... .lO..I._..___.'Pro Line ..-, -'. _:......... f p. I EACHING LINE (� No. of Lines __'D- Length of each fine.-_-. ..... Total L'engt ._ . _ ..: ....... 19-nearest: D' Box . �. Type Filter Material .. _k....Depth Filter Material .....................Distance Well ... ."-.....7Fovhdatian .: 766perty Lme .. ............... Sff�A+G 'PhT00 , Number ' ' ft�orlc 'Fa11ed Yes M No Water Table Depth .......Rock Size i I FTr i k Distance to nearest: Well ................_......................Foundation .................... Prop Line ......... ........ ' REPAIR/ADDITION(Prey° Sanitation Permit ..........................................._ Date Septic Tank (Specify Requirements) _....".......'� ------------- ............................. ...--- -••••_......------- Disposal Field (Specify Requirements} - �- �, `-' — .... � .......... ................. ---........ ......... :........__ .. q w._.....: -•........-------•.............. ...................... . (Draw existingand required addition on reverse side) y , F i;hereby certify that 1 have preparedathis application and that the work will be done in accordance with San Joaquin t County Ordinances, State-Lpws, and"Rules and Regulations of the San Joaquin Local Health District. Home owner or ficen- 4d agents signature certifies the following: "I certify that-in the performance of the woik for which this permit is issued, I sholl not employ any person In such manner cis to becomeiubiect to Workman's Compensation laws.of California." l Bi - Signed .............. . ........................................................ Owner w By .....-----_--------. . ........... .. .'................................. .:, • Title ................ her than owner) �. FOR DEPARTMENT USE ONLY s APPLICATION ACCEPTED BY DATE........--- n .- ......... R'-----._ .... . BUILDING PERMIT ISSUED ....... ....... .......... A"DDiTIONAL COMMENTS -...... ...... .._...__... ................: DATE • :....... ....................•--•------..:.._....-----............ �.................... ....................................................... s ............................. _...................................jj .._....... Final Inspection by: .... .......... .. ....... .........:....................._.......... ... ............._Date ....... :�.�.- :..1................ SAN JOAQUIN LOCAL HEALTH DISTRICT i E H 1.3 241-'68 Rev. 5M 7172 -1-M