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FOR OF,,FICE11SE: AMICATION-FOR .&ANITATION PERMIT Permit No. ------------ ---------------------- --- (1 (CompleteG = ° in Triplicate) , -------------------------- --------------- I` � Date Issued _.!ll��.__. I -_---------_-- This Permit Expires ] 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. 549 and existing Rules and Regulations. .I JOB ADDRESS/LOCATION -------------------------------------- --°---------------CENSUS TRACT -------------- ----------- Owner's Name ----1�,9,o -- .Phhone ----------I---------------------- -- -- G' TJX----------------------- _ .....•...........: Address .------c�- -- -�-•.._ -�------------ -- --� �-�----- -- - ----------------/� city gyp-' Contracto`r's Name -`-�----.License # ��hone !'. Installation will serve: Residence rtment House-E] Commercial Trailer Court i❑ Motel ❑Other -------------------------------------- '; ` g -Garbs r �'- •� �---�--`----- ------- Number of living units:____ yy_ Number of bedrooms __ Garbage Grinder llla :-� Lot Size ___•____ ___________ __ F . , Water Supply: Public System and name = aJ -v`-� �n ---------- --------- Private ❑ cter of soil to a de th of 3 feet: SandSilt; Gay E] Peat El Sandy Loam '❑ Clay Loam.0 Chars p ❑ ,❑ . . . _�__ �, Hardpan E] A`dobe'jr Fill Material .TUU__If yes,type E--------------------------- ' plot plan, size of lot, location of system in relation to welds, buildings`, .etc. must• be placed on reverse side) ( p , 14! is available within 200 feet,) permitted if public sewer No se tic tank or seepage it er pr NEW INSTALLATION: ( pP P � I!: PACKAGE TREATMENT ' Size.---- ---If ---------------- Liquid Depth __ / ...... --• Q [ ] SEPTIC TANK�( Capacity ). 3�________ Type 4� -_ Material 3 nGNo. Compartments _�.............. t l- k Distance to nearest: Well -----------------Foryun�datipn _ _-��___________.Prop. Line __�_____________ / J LEACHING LINE No. of Lines _._ _________ -- Length of each line__ _____________ -- Tdtal Length : f -..------------ , � y 1 1 I/ 3 R F i 'D' Box _y__4�. -- Type Filter Materiallll�.i1-�_�CUepth Filter/ Material --------- 1--___._.--�---------------- . E II' Distance to nearest: Well �~_-________ Foundation //0-1------------- property Line. ------------------- SEEPAGE PIT ] Depth _ _ _______ Diameter:;Q =---- :_ __......-____ Number _____ ____ _____ Rock Filled Yes]- No C] _ t 11 Water Table Depth ----�_U_ --- ----------------------Rock Size, l� t I r Foundation Q_______-- PropLine _ '�____-- ` Distance to nearest: Well -------------------------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---- --- -------------------------- PtTank (Specify Requirements) ---- w _ A ) - -DisosaI (Specify Requirements) -------------------- -------------------- - -:- ------ ---------------------------------------------------------- r' _______________________________________________�__-______--------_________________-------_._____--_---------___________-___-__-_____________-_-_-__________-___________----_______________.___�_ (Draw existing and required addition on reverse side) I hereby certify that I have prepared this�applicatid—h end -that; ie work"wil1' be lane in decordance with San Joaquin ' � } licen- �' f the San Joaquin Local Health"mistrict. Home owner or State Laws and Rules and Re ulations o q County Ordinances, 9 ' l it sed agents signature certifies the following: it; I "1 terrify that`ir ,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." i . a Signed - ---------------- ] ------------ Owner s i L i11 -- ------------- Title �.: --- BY _47 -------------------------------- -- - ' (If other than ner) FOR DEPARTMENT USE ONLY ] APPLICATION ACCEPTED BY ---'-- --------4 _ ¢ ,` � DATE ---y ,1~1 ------------------- ------ - - -- ADATE ----------------------- -------•----------- BUILDING PERMIT ISSUED ------------------- ---------------- ADDITIONALCOMMENTS --------- ------------------------------------------------- -------__---------------------------------------------------------------------------------------- f_r--------- ----------------' ----------- } ------ .i ----------------------- ------------- --------------- -- ' ' ------------ ---------------- ---- ---- -----------------' s, - Finallns Inspection ate "_! �-- ----------- -- - - py-. C:-- -- -`--- ---- -----------------------=------------ SAN JOAQUIN LOCAL HEALTH DiSTRI& . E. H. 9, 1-'b8 Rev. 5M,_ � '7