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FOR OFFICE USS: + TION FOR SANITATION PERMIT APPLICATION / r. -------------------•---------- (Complete in Triplicate) Permit No. ----- - ------:.T.-�. . _ --------------------------------------------------------- --------------------- ----------------------------------- This.Permit Expires 1 Year From Date Issued 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: JOB ADDRESS/LOCATION M----------------------- - ------- tI-l0- ------------------------------------------CENSUS TRACT - -------- -------- Owner's Named (- '! yt/Cz�-- Phone Address 7 �� - �//` Q�Y---- - ----------------=------ City 1/ G° ------------------------------------------ Contractor's ----- -------- ------- 1 -� ------------- -------License # 5'_. � -__ Phone -" Contractor's Name ___ -_ _.� __ _.-__�__� __ _ f - Installation will serve: Residence [:] Apartment House❑ Commercial ❑Trailer Court k Motel ❑Other --------------------------- -----------•--•- Number of living units---------- Number of bedroomsf--------....Garbage Grinder ------------ Lot Size -------------------------------------------- Water Supply: Public System and name ----t=----_---^`_"4` -- ---------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay .❑ Peat❑ Sandy Loam -❑ Clay Loam Hardpan ❑ Adobe '❑. Fill Material_.--,__._,_- If yes, type ---------------------------- (Plot -------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) 4 y NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ." PACKAGE TREATMENT [ j SEPTIC TANK'[ j Size-----------------------------------.----- Liquid Depth --------------------------- Capacity ------- ---------- Type -------------------- Material------------ --------- No. Compartments ---------- -••=-_---- Distance to nearest. Well ------------------------------------Foundation ---------------------- Prop. Line --------------- ------ LEACHING LINE [ j. No. of Lines- ----------------------- Length of each line-`------------------------- Total Length ------------------- -------- 'D' Box ----1.__.-_--- Type Filter Material --------------------Depth Filter Material ---------.----- - Distance to nearest: Weil ------------------------ Foundation --------- ---- Property tine ! ` ------__-.--._N_--o_- --_ RSEEPAGE PIT Depth --- Diameter ---------------- Number ----.--------------- ockfi%" Vec .- ❑ Cl 4 Water Table Depth ------------------------------------------------Rock Sire ------ --------'--•----- ---- Distance to nearest: Well -----------------------------------.--.-Foundation -------------------- Prap. lig --._.-_.__.._•-•-.-- WAIR/A0011WO(Prev. Sanitation Permit# --------------------------------------I--------- Date ----------------------------------I K SepticTank (Specify Requirements) ---------------------------------------------------- ---y------------------ ------------------------------..--------------------------- Disposal Field lSpecify Requirements) ------)_9DI --------Dt T-=---,ax'--------lQC?---------- Ft1!�-k-----�4j-, ..................... ------------------------------------------------------------- ----------------------------------------`-------------------------------------•-----------------------------------_-•--------•---•--------- (Draw existing and required add _ ition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqvin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Nome 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 � . to beco su ' ct to rkman's Comp cation laws of California." Signed __ _ __ __ Owner --------- By ------------------------ ------------------------------------------------------------------ Title ----- -- -- (If other than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ------ -O---------- ------------------------------------------------ ----'' ----- DATE ----- BUILDING PERMIT ISSUED - - --- -------- - ---- DATE - -- ----- ----------------------- ADDiTIONAL COMMENTS -------------------------- ---------------------- ---------------- ---- ------------- -------------- -------------------------------------------------------------------------------- ------ ------ -- ------------------------------------------------------------------------------------- ------ --= ------------"�------ c - --------- ---------- Date ----- - --- --- - -- - ------ -- Final Ins ecti Da :-- T - . -. - p C �� - - to SAN JOAQUIN LOCAL'HEALTH DISTRICT E. H. 9 1-'68:.Rev. 5M,