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FOR OFFICE USE: c APPLICATION FOR SANITATION PERMIT Permit No. ----.�-�` f1 '_ .----------------------------------------------- �.i--� (Complete in Triplicate) _ __ Date Issued -" --� •-�-"- -"---"- -"--"" --"-"--"----------------- y _"_ ----_ " _ - :This Permit Expires 1 Year From bate Issued - ------------------ - rict for a rmit to and l the work Application is hereby made to the San JoaquinLocal ecwith CounDtytO dinan a No. 549 and existing Rulestalnd Regulatonsrein described. This application is made„in compI ; CENSUS TRACT - JOB ADDRESS/LOCATION - °-'� 1L r -------------------Phone919x---4. Owner's Name C.r41-c.C,---- a ---------------- City ,, Address hone ES�"f _-------- O e Q License # Contractor's Name ---- A ------ Installation will serve: Residence XAportment House❑ Commercial ❑'frailer Court MotelR.w,Other ------------------------------------------ 4 .�.ey..xseyxw, ♦- Garndef ___-_____ __ - Lot Size "_ -� � - Number of living units:-----'____,Number of Bedrooms -4— --- bage GriPrivateX Water Supply: Public System and name -------a-------------------- - 4 4Peat❑ Sandy Loam Clay Loam [ICharacter of soil to a depth of 3 feet: Sand I❑ Silt❑ Clay ❑ yes,: Hardpan ❑ Adobe-E]. Fill Material ___- ------ If es, type ---------------------------- (Plot plan, showing size of lot, location of'system in relation to wells, buildings, etc. must be placed on reverse side.)3 I NEW INSTALLATION: (No septic tank or seepage pit per ,if public sewer is available within 2b0 feet,) !` Size""��-d--�-�- -��---I---- Liquid Depth __��-------------� PACKAGE TREATMENT [ I SEPTIC TANK ! _ Material ! 4_,_e__4-"No.-- C o-m artments ------ 2 �Capacity Jo � -- _ Prop. Line _-- Distance to nearest:-Well--_- ------ �--- = ti i Fundation 6 s40-1--------- LEACHING LINE No. of Lines 3- --------------- Leng of each line__- ----- --__ Total Length ,..�-- •- D' Box ---1------- Type Filter Mate �I--- -- -YAPept�Filter Material "._"- ---- I l �> Foundation ------------- Property Line. ------------------------ r r SEEPAGE PIT Distance to,riearest: Well -.______-- L . - Diameter "____ Number`------ --------------- Rock Filled Yes No i❑ �— Water Table Depth __ .--- Rock Size ------- ------------ .. «:. r Line ----------------•-- �� D Foundation Prop.. 'Distance to nearest: Well __________ ----------------- .«�. .,.._•�_;-- .._....�^� ..�.=� ^'- �., �_ ,�. � -----''------- -- ate ----------- -------------------- -} REPAIR/ADDITION(Prev. Sanitation Permit# -------- -------- Septic Tank (Specify Requirements) -------------------- ----f-- ------------------------- ------ Disposal Field-(Specify" equiree `Rmnts) --""------------ ------------------------------- ------------- ------------------ --- - z --- .. ------ - ------ --------Draw - -----------and---------------- ----------------------------------------------------------- {Draw existing required addition on reverse si del I hereby.certify that I have prepared this application and that the work will be done in accordance with San Joaquin r County Ordinances, State Laws, and Rules and Regulations Of the San Joaquin Local Health District. Home owner or licen- sed agent's signature certifies the following: erson in such manner -I certify that in the performance of the work far which this permit is issued, I shall not employ any p " as to become sub' c to Work m Comp nsati.on laws of California." 1 Signed ------------- Title ------- --- ------------------------------------------------------------ (If other than owner) FOR DEPARTMENT USE ONLY 7L-`' .; _ _ DATE -_._�--------- ------------------- --------------------- ------- ---- ------ APPLICATION ACCEPTED BY .-- �.(,a<r --"-TE -------. _ ----------•--- --------- - _QA BUILDING PERMIT ISSUED ---- ----------- r -'=-------[- ----------------- ADDITIONAL COMMENTS -..Z--- -- ------------------------------------------------------------------ ----------i--------------------------------------- ----- - -- ------ -- Date----------------------------------------------------------------------------------------- - - -- ----- rFinallnspection by: _.__ ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6B Rev. 5M _.._..