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FOR OFFICE USE: APPLICATION FOR ,SANITATION PERMIT Permit No: (Complete in Triplicate) �d /:_ ��- a> it Date Issued This Permit Expires 1 Year'From_Date Issued A lication is herela made ---------- --------------------------- pP to the San�7oaquin Local Hedlth`Di''st�PEf'#`or"'a"perrriit'fio'eonstrucf and install the -work herein described. This application is made in compliance with County Ordinance,,No. 549 and existing Rules acid Regulations: ;3� W�v j JOB ADDRESS N:,r--- /_~] : c Y _/-t) '�----------------------CENSUS TRACT _._. ___ ^_-^-. i � �- _ r, ' - - one__ . - i"> _: Ph - - --` Owner s -Name - „�.. --------------------------- --- Cii•;;�_, _ Address ----�i-(1. ; L>✓_ = Lrcense. ~--~'_ .__ - Phone :_ Contractor's Name -_ -------- ^ �, E �•y- c Installation will serve: Residence VApdrtme'nt douse'❑ Commercial ;]Trailer Court-'❑ } f r Motel ❑ Other -------------------------------------- --- 17 plumber of living units------I_-__- Number of bedrooms ___3 Garbage Grinder 1/gImLot Size --_ r Water Supply: Public System and name --------------------------------------------------------- -' Private ;, Clay Loam Peat,❑ Sand Loam..❑ Character of soil to a depth of 3 feet: Sand'❑ Silt C-1Clay E] Peat, Hardpan ❑ Adobe.E Y € Fill Material If es,typ --------------- (. it (Plot plan, showing size .�f lot, location of system in relation to wells, buildings, etc, must be placed `on reverse side.) r NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200`feet,) 't04 PACKAGE TREATMENT SEPTIC TANK f ] Size--------------- - _---�Q Liquid Depth's r"l'I 1,, I / Capacity -------------------- Type -------------"------ Material � �CNo. Compartments ---- Il A Distance to nearest: We11 ___"____"-_ --foundations Prop. Line_____________ '�: Length of each line'-------`� --------- Total Length _._----"_--•• -•------------ 0 � D © i�. of Lines g i LEACHING LINE � N , D' Box ------------ Type Filter Material --------------------Depth Filter Material -----------------'-------------- Ils�� Distance to nearest: Well f'�_- ---------- Foundation .___ —0--------- Property, Line,r �-_..----•-•-•- // r SEEPAGE PIT D�pth __ ------- Diameter __, -__-- Number -----------"Q _-___ -- Rock Filled Yes No �❑ f Water Table Depth ----------------------------------- --------Rock Size -------------- --- il, ' Distance to nearest: Well ------------------------------------•••-Foundation ---------------•---- Prop. Line _-------__•--•--- - ------ ---------- --------- Date ------------------•---------------) REPAIR/ADDITION(Prev. Sanitation Permit# _----------- -- - r :I1 ------ -1-------------------------- Septic Tank (Specify Requirements) ------------------------------------------------------------ ---------------------•--------------- s . L E Disposal Field (Specify Requirements) -- ----------------------------------------------------------------- I .I: -------------------------------------------- ------------ ----------- -------------=---------------------------- ------- -------------------------- t (Draw existing and required addition ontreverse s4616 � u - I hereby certify that I have prepared this application and that the workwill be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner f as to become pet # r n's Compensation laws of California." y �� --------------------------------- Owner Signed - - - ----- ---- �� ---------------------------------------------- Title (if other than owner) FOR EPA USE ONLY I� 2 APPLICATION ACCEPTED BY -- ---_--- r- _-- . DATE _- --------- ------ - ------ ------ -- BUILDING PERMIT ISSUED --------------------------------- --------- ---------------------------- --------- - ------ DAT ----------- -------------------- ADDOMMENT�S --------------------------------------------------- ---------------------------------------------------------- f --------- _�� ----- __----------------------------- - --- - Final Inspection b -- - ----- -- - ------------- -----------------------------------.Date ---- ! NQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'66 Rev. 5M: