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FOR OFFICE 4Jsl:s IAPPLICATION FOR SANITATION PERMIT Permit No. .._7�`��• �, ........................... ............................. (Complete(Complete In Triplicate) —7c ..... .......................................... 4 Date Issued /2-- ....... •-, This Permit Expires t Year From Date Issued '} 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. 544 and existing Rules and Regulatlonst JOB ADDRESS/LOCATION ....�i 4� '-.� ..RiPP :...Ret.......................................,......CENSUS TRACT ................... Owner's Name ....... ..... FA.g`r,q'4�.... .................... ............................._.....Phone Z4.9t.K6'. ........ Address -....-....-•----.�19. 9.........................-................................._......_....City ./��/ /!!. f?.............. 3..........� ••- i Contractor's Name J %��!! 4� � >f_. 5 f ........................License # . A -� . Phone Installation will serve: Residence❑Apartment Housed Commercial❑Traller Court ❑ t L Motel g}Other.... ---V`_•_. er!�!i 51`�I�}"i @ N Pe�Sv�✓A+� k a a '.. E Number of living units:............ Number of bedrooms Garbage Grinder Lot Size rCs.:..._.......'.... IN Water Supplyz Public System and name ........................... -- ......•.__-.-..---....-----.. ....................._........... - .............Private r Character of soil to a depth of 3 feet: Sand IM Silt 0 Clay ❑ Peat❑ Sandy Loam ❑ day Loam❑ R Hardpan❑ Adobe❑ Fill Material ............ If yes,type............... ............ (Plot plan, showing size of lot, location of system In relation to wells, buildings, etc. must be placed an reverse side.) " NEW INSTALLATIONS (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK j Size...................•-•-•y••----........--•...... Liquid Depth ......................... Itr ' ............. Capacity ..8¢�-�'� � Type �� f�'�s�- Material.... _P..M..Ca._.. No. Compartments Foundation Prop. Line - !7$.•.•• -.. Distance to nearest: Well ____•-•--��---•-----•---• ....-•--•-- .... LEACHING LINE ( ] No. of Lines ------- - -------• Length of each line.........?'#'-'••-••-•-••• Total Length ... a.`................ 'D' box ..../-...... Type Filter Material At -.....Depth Filter Material .....�.y. i j S�-`.:......_.__ Foundation Property Line ..... 5-.......... Distance to nearest: Well _ SEEPAGE PIT [ } Depth Diameter ................ Number .................. ................... Rock Filled Yes ❑ No C7 Water Table Depth Rock Sire ................................ , Distance to nearest:Well .....................................I Foundation ................ Prop. tine ...... 4_ REPAIR/ADDITION(Prov. Sanitation Permit .. Date ...................I.............. ) f ' Septic Tank (Specify Requirementsl •.........................._....---••_... ._....._.............-----•........................_.__._..._. ............_.........3_ f, . . ................ Disposal Field S eci Requirements) . ......................................................... t: . ,• ......................---•---•.._•--••• • ......._... . (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 Local Health District. Horne owner or liven- sed agents signature certifies the following: "I certify that to the performance of the work for which this permit Is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California" Signed .......'!� So!E ... ............................... Owner .......... ... - . _ 3 itle 11 a owner) ' FG DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...................................... DATE , . . ._... ._. :. BUILDING PERMIT ISSUED DATE ..-....................... ................... ADDITIONAL COMMENTS ......................................... .......................................... ........ ..................................................................... .......................................-.... ...........:..................-..................................................... _..__.-.:.. '. -_.. . ate _ Final Inspection by: _ - •D .; EH 13 24 1-683 v. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 6/7!i 3M J 1