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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------------------------------------- iComplete in Triplicate) Permit No. 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: f JOB ADDRESS/LOCATION . tr7 .__- -^�- I.I. TI`lJ� ,— _ K:. CENSUS TRACT. ;, Q---- Owner's Name - nr�11-_S------- -------U r Phone A -- --_-.-w__ w - ---_. ��_ —..�__ _ .. .�.�_ _ __— _ __ —_ ! p ___ Address _Z33_63___- S-----CYPlRES-----1 IN_ -`--------- City - � 1 ��--- ------------------------- Contractor's Name _MURV License # - ------ Phone ------------------------------ Installation will serve: Residence or9partment House❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other -------------------------------------------- I g i Number of living units:-----I------ Number of bedrooms ---3----Garbage Grinder, _ '- Lot Size _._ 4—_ -- ---------•--- Water Supply: Public System and name ------- SJ - ----------Private E] rt, Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam ❑ Hardpan Adobe' Fill Ma#erial _/ o E -E] ___ If yes, type -------------'-_-________--- W . (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on ;.reverse side.) W NEW INSTALLATION: (No septic tank or seepage pit permitted ift`public°sewer is available within 200 feet,) ' >i1 PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Siie?- ----"_''- --'`:-`_#"°°- --------------------- Liquid Depth ....................--- �A Capacity - -------------- T)pe -------------------- Material---------------------- No. Compartments ------------ .- ..._ i Distance to nearest: Wi II ---------------'--------------------Foundation ----------- --------- Prop. Line.----...---------••__-- LEACHING LINE I ] No, of Lines --------- -------- _ Length bf each line-----------------`_:"'. Length---- Len otal"'l:en ----------•--•-------------- 'D' Box ----- ----- Type Fil er Material `__________________Depth Filter Mater al --------------------.E___.___...------...... Distance to nearest: Wel ------------------ _____ Foundation --------- --------- ;Property,Line __---------. .- SEEPAGE PIT [ ] Depth -.-.________________`r,Di-a eter—`______ _____ Number ______-_.--- ---------- Rock,Nlled Yes E] No C]� C - Water Table Depth -------- ----- ------------------------ -----Rock Size ----------------------'---Y--" r Foundation !- Distance to nearest: Wel - `--------------------------------- on --------- - -- ---- Prop: Line ..--------------_-_--- } REPAIR/ADDITION(Prev. Sanitation Permit# ______ ______ Date______ __-_____ ___: _-)' } Septic Tank (Specify Requirements) ----------- ----------------------------------------------------------- ---- --< -------- ------------ Disposal Field (Specify Requireme } --------Requirements) -, - F LFCF �1-ni . �. -- 13F—� v �`` 5°� m �nit � � -_//►rfif3�. 4i[1 (Draw existing and required addition on reverse side) f a I hereby certify that r.I haveaprepared this application and that the work will 6e done in accordance with San Joaquin County Ordinances;State?La`ws,•and Rules and Regulations of the San Joaquin Local Health District{Home owner or licen. sed agents signature certifies the followin "1 certify thq in the,pe once of the ork for which this permit is issued, I shalt not employ arty person in such manner as to b subiect� F man's o ensation taws of California." Signed -------- -- --- ----- ---- - - --- - ------------------------------ Owner _77- By --------------------------------------------------------- � - Title ------------- ---------------- ---------------------------------------- ----------------------------- (if other than owner) t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------�-13`-C?------ -------------------------------------------- --------------- DATE _- --- _-7------ } BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ------------------------------------------- ADDITIONAL COMMENTS - ----------- ------- 1 ------------------------------------- - - -------- --------- ----------- ---- --- ---------------- ------------ ---------- - ---------------- '. ----------- - ----------------- -------- - --- ---- --- - -------------------------------------- ------ Final Inspe • by: -- - - - - - ------------------------- ate ---- -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6£i Rev. 5M.