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FOR OFFICE L►sl:: APPLICATION FOR SANITATION PERMIT ..............:.... ... ..._...�....: Permit Na . lComplete In Triplicate) ..V Date Issued 0..:a� 7 _ S• This Permit Expires 1 Year From Dat*Issued t 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 with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATI .....-CENSUS TRACT ................:......... Owner's Name -._`•-- ................:... .. .......Phone .. -_- -- -- -•-•-•-. Address -- ------- fi--- ---- .....City .. .... c� / 7 Contractor's Name --•-----••-- _-•-• -_-__. _.~ _ ._ ._._ ::__:_:License 16` 3:1.3...... Phone �46.�e_0Z----- installation will serve: Residence Apartment Housef] Commercial OTraller Court Cj •1 Motel ❑Other............................................ I Number of living units . Number of bedraoms`__y::Gorbage &rider ..._.._. Lot Sh x� ................. t Water Supply: Public System and name ....:....:...... - .......-..-...Private ❑ Character of soil to a depth of 3 feet. Sand O Silt O Clay O Peat Q Sandy Loam o Clay Loam o Hardpan I] Adobe Fill Material y , .. lf es type............... ............ (Plot {Dian, 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 publ€ ewer is available within 200 feet,) i e( PACKAGE TREATMENT j ] SEPTIC TANK _ _'� v i r i ; qDepth CcpacitY:fYpe Mat ial. ... No. Compartments ........ - ...... .-.. . N ti Distance to.nearest;-Well ________________ --------------Foundation « Prop. Line _...,.._ : LEACHING LINE No. of LLi a _--f.... __.._.._ Length of; ch iris.-----... -d----------- Total Length ....... �______________ r " 'D' Box ._. .. lype-Filter Material ..: . .. .........Depth filter Materia l ... .....-.........__................ -.-•- -. s Number .....t%._._. .......... .............. Distance to nearest: Well _____________ __ Foundation 1.�....T':.... PropertyLine ..__-_-... SEEPAGE PIT " (j Depth ._... _ :_.___. Diameter __V ________ Rock File.led Yes 9 No Water Table Depth .........................:.:..•.._..•.-_._.....Rock Size W�t_l -�--.-_ r Distance to nearest: Well _____________________________________ Foundation ..P.t}___---__---- Prop. Line ...._ ........... t REPAIR/ADDITION(Prey. Sanitation Permit ` __ Date ) Septic Tank (Specify Requirements) Disposal Field (Specify Requirements) --- --••--- ------_•---------------------•----,-- IKIM ................................................... ......................... --- ••. ...... • -------•- - , ..-•- t ------------------------------ --------------- -------•-- (Draw existing and required addition on reveise-side) I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joagvin County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Hoalth:'District. Home owner or Ilcen- sed agents signature certifies the-following:, "I certify that in the performance of the work for which this permit Is I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." ( Signed --------- --•-•------- ................................. Owner BY ------- ---•- �.. Titie -----........................ (if other t owner{ _ R PJPARTM5ps USE ONLY APPLICATION ACCEPTED BY -- 14 -------•---------- DATE BUILDING PERMIT ISSUED -__-•- .................................. DATE --------------- ADDITIONAL COMMENTS ---------- ••---_ -. .:..........:,..........................._.__.,......................................................... ------------------ •-•--•---...._.._ ------------------------------------------------ .............--•---- ........ ....................... --------------------- ---`--- -----`-- . --- ----------------- ------ --- -- i' f-- �-- �� l.. Final Inspection by: ----- CJ.. ._ _� L-------------- .----------- ....._Date • 13 21 1-613 Bev. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M