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i FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT , --------------------------------------------------------- Permit No. ----- (C mplete in Triplicate) ---------=------------ ------ --------------------- N t /�✓` 'wDate Issued -�:�`l-_-��-�--• T i er r x tr s ear From Date Issued ( 5'a_G� uJ �S'iac� .iS� ^i;o Application is hereby made #o the San Joaqusn,LocaI Health_District for a permit to construct and install thework herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION�vv CENSUS TRACT -------------------------- Owner's Name f �__., � -- ----- ------- _:---:_:------ ---------�--� --------- Phone ---------- Address zfilG �l�6" /7 ,�� E �' l' t�J�f - I � _. City - ---- ----- -------------- Contractor's ------ -- - -- - - - -- - - Contractor s Name '----------- ----------------------= ------LicensePhoneX-011.ZI ----•-- Installation will serve: Residence ❑ Apartment House,❑ Commercial ❑Trailer Court i❑ M01W,-E] other Number of living units: ----- Number of bedrooms _ -_-_-_-Garbage Grinder - f'- Lot Size 1 - + Water Supply: Public System and name ----------------------- - -- -------------------------- Private,' Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam.W Clay LoamE] Hardpan ❑ Adobe ❑ Fill Material --------If-yes;type ------ (Phot 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 publicsewer is available within 200 feet,) i o SEPTIC TANK' -06------------------- Liquid flepth ------------. PACKAGE TREATMENT [ ] - if Capacity TYP ---- - �Material 4'0,_"' r No. Compartments - ..------- -Foundation _,� ~--------- Prop. Line _/_6V- ----' , Distance to nearest Well ___ ------------------ i ��;�A' Len th of-.:each line,, --= - -- Total Length .7=. ------ --- LEACHING LINE [ ] No. of Line�"�_-- --- - g � �+ D' Box -__ Type Filter .Materia _ ep#h Filter Material ! __ _---'----------------•------•- Fouridatio Distance to nearest: Well ______________ _ --------- ---- Prop`e�ty Line fp ----- inDepth Diameter ---------------- Number ----_-- ------------------ Rock Filled YYes ❑ No ❑, SEEPAGE PIT [ ] P ------------ - ;' Water Table Depth ------------------ ---------- •------- ----------Rock Size -------------- ---- k k - Distance to nearest: Well ------=-----------------------------=•---Foundation -------------------- Prop. Line ------------------- +.: REPAIR/ADDITION(Prev. Sanitation Permit# ------------`------------------------------- Date ---------------------------------- Septic Tank (Specify Requirements) -------------------------------------------------------------- - `} = =;----------------- ----------------------------- { 1. Disposal Field (Specify Requirements) ----------------------------------------------------- ----t----`--- ,- ;--------------------------------- ''�. ------------------ -- - ------ ---------------- -------------------------------- -------- -- -------------- -------=-- (Draw existing and 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 Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: F "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner ' as to become subject to Workman's Compensation laws of California." Signed ------- ------ ---- --------- ------------------------- ----- Owner Tit Iei BY ---- --- -- -- -- �/ - F --------------------------------- , f other than owner) , FOR DEPARTMENT USE ONLY ` APPLICATION ACCEPTED BY ------ _. - --- ---------------------------------------------------------------------- DATE _ 5------ ---------------- BUILDING PERMIT ISSUED ---------------- -------------------------- ---DATE -------------•------------------------= --------- --- -- ADDITIONAL COMMENTS --------------------- ---- --------------------------- ------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- -- ----- ------------------------------------------------------------------------------------ -------------- ------- - Final Inspection by: ---�-''--------- - ----- - --------------------------- -------------------- - -- - --- - - Date _ .JY ------------- 5AN JOAQUIN LOCAL HEALTH DISTRICT r L1 0 1--'AR Rav J;M