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FOR OFFICE USE: APPLICATION1 ` Vt SANITATION PERMIT Permit No. ---------- ------------- [Complete in Triplicate? / ---- -- ------ Date issued This Permit E�'pires'l Year From Date issue Application is hereby made to the San Joaquin Loc Health District for a permit to construct and install the work herein decribed. This application is made in compliance with County Ordinance No. 549/and existing Rules and Regulations: " = ------CENSUS TRACT --------------•----------- JOB ADDRESS/LOCATION .-----�--- ---.------Phone Owner's Name --- ---- ---- ------------------------------- -----•-- ------------ �- +-------------- - City --- ----- ----- ---- -21 -- 1 Address --- __ 0 t 7_ (Phone { � _<ar.License # Contractor's Name Apartment House�❑ Commercial Trailer Court Cl Installation will serve: Residence Motel ❑ Other -------------------- -- ---------- -- = Number of living units:---- --- Number of bedrooms ---�--Garbage Grinder _ O___ Lot Size J - Private Water Water Supply: Public System and name _--_--------- --------------- Peat Sandy Loam ❑ Clay Loam �-' Silt Clay .� ❑ Character of soil to a depth of 3 feet: SandE] ❑ Hardpan Adobe-0 i , - � 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.} it ermined 'if public sewer is available within 200 feet,) f� NEW INSTALLATION: (7SEPTICTANK�[ J tic tank or seepage p' p ,� O Size--- ��- - Jt---� ------ Liquid Depth --..__�-- ---•------ _ - PACKAGE TREATMENT - Na. Compartments ------�•------- _ Type If------ -- Material&-R_ ,t Capacity ; Foundation _____________ Prop. Line ._ � R Distance to nearest: Weil ________, �------- _ �� - LEACHING LINE No. of Lines ___.- - --------- Length of each line--_--=- � _.-_ Total Length ,_-----f---•---- j __.__ —' � Type Filter Material ______________------Depfih Filter Material _._____-��-----•-� � i Di Box _ �� Pock Fill SEEPAGE Yes �No i❑ Foundation _C_'S R p tY ---------- Distance to nearest: Well ---- ----- ----- � Y � i Number --------- -- Diameter -------- ----- - SEEPAGE PIT Depth - -- ---- r y?//- * /O f Rock Size ------- - ------------- Water Table Depth ------- - --©-- f ------- Pro Line -6- ......... Distance to nearest: Well _.__/C�----------- ----------- Foundation �5�--- p• k REPAIR/ADDITION(Prev. Sanitation ermi .------•---- - --.------Date ------•---------------•-------�-------) Septic Tank (Specify Requirements --------.----------- --------------------------------------- --- ----- Disposal Field (Specify Requirements) ______________ ----- i ---------------------- -------------------------------- (Draw existing and required addition on reverse si e prepared this application and that the work will be done in accordance with San Joaquin I hereby certify that I have prep r County Ordinances, State Laws, and Rules and Regulations of the. San Joaquin Local Health District. Home owner or licen- i sed agents signature certifies the following: for which this permit is issued, t shall not employ any person in such manner "1 certify that in the performance of the work 1 as to beco subject to r an's ompe ation laws of California." I Signed _. . —----- ---------- Owner ----------- Title r . By -------------------------------------------------------------- (if other than owner] �. x . FOR DEPARTMENT USE ONLY DATE - --""! •e-- L1 _ _r- --------------------------- --- ------ DATE ----------------------------------- ------------------- APPLICATION ACCEPTED BY _� - ------- - -- -� ----- ----------"----- BUILDING PERMIT ISSUED -------------------- -------------------------------------- ---------------------------------- ---------------- ADDITIONAL COMMENTS --------=-----------�-- -- ------ -- --------- - ---------------------------- -------------------------------------------- --- -- ----- -_ --- -- --------------------------------- ------------------------------------------------- - -- --- -------------------- ------ ----------------- . - ------- -- tDate ------------------------------------------- Final Inspection by; --- - - --- ----------------------------------------- -- - --•- --- ' SAN JOAQUIN LOCAL HEALTH DISTRICT C�p c u 0 1_,6A Rev. 5M