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FOR OFFICE USE: a~� 30 "" APPLICATION FOR SANITATION PERMIT s �� ------- — �d (Complete in Triplicate) Permit No. ---------------------------------------------- -------------------------.._______.-____.__________.__ This Permit Expires i Year From Date Issued Date Issued ( t Cl-os{7 �`f/ 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 � ,s' _�.. JOB ADDRESS/LOCATION *IVi t/__Yc'_1':---- -f-- --- '- „_-_--_. -- .---CENSUS TRACT ------ ---_---- Owner's Name ---- --- _ - -. -�- ----------------------- ---------- Address ----- `. '- --- ------------------ City Contractor's Name .-------- aC$F -� -------------------------License #/e�,Z-407 Phone Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ',❑ Motel ❑Other --------------------------------------------- Number ------------- -------------------- --Number of living units:_______ Number of bedrooms ______Garbage Grinder/----- Lot Size Od________________ Water Supply: Public System and name __e,60Z,6�--_ _---------------------------Private El Character of soil to a depth of 3 feet: Sand'❑ Silt p Clay E] Peat F1 Sandy Loam E] Clay Loam ❑ 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 on reverse side.) NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) r - ,moi /� PACKAGE TREATMENT { ] SEPTIC TANK'Vy r Size__ __ to ____________________ Liquid Depth $�4C------------ Capacity/2" _____ Typed Material_- r_� No. Compartments _.' -1-----_----- . Distance to nearest: Well -----,- - --------_M't--------Foundation --e--------------- Prop. Line -------------- +� LEACHING LINE No. of Lines _�__ _______________ Length of each line_.. ----- --------- Total Length ---4P_�.......... ffW -- 'D' Box /W---- Type Filter Material/` �4?4� Depth Filter Material _ff--------------------------------- Distance to nearest: Well ----- �________ Foundation -_-_._/ ________ Property Line - _7.!____._____ SEEPAGE PIT [ 1 Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes No C] - _--_Water Table Depth --------------------------------------- --------Rock Size ----- -------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -•-------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------- -----------------------:--------- Date ----------------------------------) Septic Tank (Specify Requirements) aw° --------- .; { Disposal Field (Specify Requirements) ---- ,1 /� -�r ----- ---------� l-�jC� ----- - •�r- �' `f , ------- -----A4a---- !� ___ta AIT—e--Z------- o- { raw exis ' (g a 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 Jbaq County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. home owner or Ii sed agents signature certifies the following: "I certify that in the performance of the work for which-this.permit is issued,.I shall not employ any person in such manner ,yas to become subject to Workman's Compensat•on laws of California." Signed ----------- Owner t ---------------- ----- ------------------------- - ---- -----------------------=---- BY ! ---- Title -- G1j = (If other owner) �f F PARTM£NT USE-ONLY ,APPLICATION ACCEPTED BY ----- ----- .-- -- DATE -------------------- 'BUILDING PERMIT ISSUED DATE --- --------------------------------------- ADDITIONA� C ME TS - -------------- - rc�s- � �' ^ ---------------------------------- , ---------- �-- - ---- --- ---- - ------- ---------- - - -- 'Q� �' a - - -- - -----�---- ----- -----¢� ------ � � _�-- -------------------•--- ------------=------- ' Final Inspection by. --- - - - ------------------------------------------------ ------------------------.Date ---- """ �------ ---------- �JOAQUIN LOCAL HEALTH'DISTRICT 1-'613 Rev. 5M x