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F R oFFlc€ USE- APPLICATION APPLICATION FOR SANrrA/i ON PERMIT _ 55� .....:................................................... Hermit No� `....._.... .----.._.. (Complete in Triplicate) r.,.._.....-.•.......................................... This Permit Expires 1 Year From Dale Issued Date Issued .......................................................:. k 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 compliance wounty Ordinonce.No. 549 and existing Rules and JRegulations: r CC 4 [� ,, r f J �, � � �� 'YI � '✓r V� 108 ADDRESS/LO -- -- CATION .._: .�1:.._...�.2_�.. --L _.1.1.L�3 .. . .._ .. i=NSUS TRA ....V.....:...::.....:.... Owner's Name C .--.- ....Phone .....-_ Address .................... _. �. .1 ........,._.. City ?l .......... �;. Contractor's Name . .... ..... ~..--------•---. License/ 1 Phone ......` sJ.'..... 1. Installation will serve: Residenceartment House❑ Commercial ❑Trailer Court C] i I Motel ❑Other --------------_....._------ - orb e Grinder . Number of living units:.........Number edro mp ...... ..`�. Lot Size ... .............. Water Supply: Publit System and name ....._ ------- --------- -- --..........................................Private ❑ Character of soil to a depth of 3 feet: Sand 0 t❑ Cl a ,❑ Peat❑ San_dy loam ❑ Clay loam 0 Hardpan ❑ Adobe Fill Material .� If yes, type ............................ I `..- (Plot plan, showing size of lot, location of. system in elation to wells, buildings, etc. must be placed on reverse side.j . NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet;) :p: PACKAGE TREATMENT [ SEPTIC TANiCV, ] ize..;tY _ l/. 1...... Liquid Depth �_._.._.- Capacity ..f�.� ----•-- Type OrL� Materia ... . .}�_[ 'No. Compartments. ........._. - Distance to nearest: Well .-_ ---.-..Foundation ..,-- Prop. Line ...................... � OQ ,�. —.. ,�.------• -- LEACHING LINE No. of Lines .. Length of ach line. . Total Len fit~ _I" ....... tam r ---�---•- g 1 1-�,�-__.. .�-��=---------------•-----•-. Z 'D' Box .'>V .ZS. Type Filter Material 1,..Depth Filter Mcifetial' ...�.__ . r Distance 'o nearest: Well Foundation ./ .............. Property Line f.......:.: SEEPAGE PIT [t4-1 -Depth .. -. _.. ... Diameter ...----.. --- Number .---.-------��....•—.---._. Roc` Filled Yes 1�o i❑� Water Table Depth .. - -- ...............Rock ....... Distance:to nearest: Well ..,._, � .................Foundation ... 0.- ...-. Prop. Line . ..._�_---.-_-- r REPAIR/ADDITION(Prev. Sanitation Permit# ........---•--•............................. Date .................................. Septic Tank (Specify Requirements) ....................:••-------....._..................---• ............. ................................... _.......-....----- 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,San Joaquin focal Health District. Home owner or liicen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is.issued, l shall not employ any person In such manner as to become subject to Workman's Compensation laws of.California." Signed ., / ......... . - ' itie . (If other th n r) ` r ° ' FOR;DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ..." 1,��.. er r . ......... .. .... ......... ...t------- •--- -••-- DATE .. _ Y BUILDING PERMIT ISSUED :.......L._...... -•--- ADDITIONAL COMMENTS ........:....... ... -----•-------- --•----•........ ...... •.... ....... . .. :................................................... Date _ Final Inspection by: -- N JOAQUIN LOCAL HEALTH DISTRICT �F w 13 24 1_'15R Rav_ 5M 7/723 M