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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------------------------- Permit No. -----2:7:x_-- (Complete in Triplicate) --------- - - i -z, Date issued ---[- /- --------- - ------ This Permit Expires 1 Year From 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 Ordindnce No. 549 and existing Rules and Regulations. OB ADDRESS/LOCATION .-----�� --'- /��-------1�;�-R- ----- -- ------------------------CENSUS TRAC3�_"5- ----------- J Owner's Name ----------�)L .f R D 1'dR, S-------- ----------------- I-------------------Phone ) s / . City -1414 ------------------------------------ ------ Address Contractor's Name ------- -- ---- - - -:--� i; Q Trailer Com- ---- Phone ---------------------------- 1/�/1� License # Installation will serve: Residence ❑,Apartment;House❑ Comrrercial ❑ s lit Motel Motel E] Other------ --------------------------------- r Number of living units:___ ----- Number of bedrooms 3______Garbag� Grinde� Lot Size ___ ��--------- i iPrivate [ � Water Supply: Public System and name ________t_ -- i ----------------------------------------------------------- _ —„,,-,..Character,of soil jo-:a_depth.of 3 feet:. .-Sand;❑ Silt[D -, Clay E] Pea.tjEj- rSar y�Loam []Clay Loam ] Hardpan ❑ Adob�❑ FiLhMaterial -W-if yes, type _---______________________ (Plot plan, showing size of lot, location of system in relt�tion to' wells, buildings, etc must be placed on reverse side.) { a idler fitted if ublic/sewer is available within 200 feet,) � NEW INSTALLATION: [No septic tank or seep ge--p ; p PACKAGE TREATMENT SEPTIC TANK [ L Size---„,a��jD X �----------- Liquid Depth __._�-.--------.----- : Capacit 120 -_,-_ T e P C�9-5� Mat iol_I-e�-C`� No. Comp,art encs ,_ ----- Y Yp r_ / I r ,—L istance to nearest: Well ----- �-� ------'--------Founds idri ?�� __- ------- PrORLine -----�---:., --- LEACHING LINE �No. of Lines ---.�------------- LerIgth tf each line___ -°° Total Length --- � -------- t aaC I / ------. - D' Box es Type Filter M��tal-- ~__�_:—___.Depth Filterr Material ---------/_T_ I------=-- Distance to nearest: Well ______-r�Foundation _._ Property Line - __`--------.--- ' SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- -Number ---------------------------- Rock Filled Yep A No 1❑ Water Table Depth ----- ------------------------RoClc Size ft,► ' ! (/1 ------- l Distance to nearest: Well �____----__�________________ ______Foundation __.__--________----- Prop. Line ---------------------- REPAIR/ADDITION ---______-_____REPAIR/ADDITION(Prev. Sanitation Permit# -------- ------------I------------ -----\' Date ----------------------------------11 _ w Septic Tank (Specify Requirements) -------------------------------- -- 4:---- ------------------------------------------------------------------------------------------------ 7 Disposal Field (Specify Requirements) --------- - s� I ---- ------- i. - -------------------------------------------------------------------------------------------------- -- g (Draw existin and re aired 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: "I certify t in th pe or ante of the work for which this permit is issued, I shall not employ any person in such manner as to bet a sub) ct to rk Compensation laws of California.” Signed ---------------�- = Owner ---------- � ( By --------------t Tfi k_f!_ Title ---------- ----------------------- ------------------------------------- ------ ---------------------- -------------------- (If other than owner) t I FOR DEPARTMENT USE ONLY q APPLICATION ACCEPTED BY ------------ 1 --- ------------------------- ------ -------. DATE _./--` 1 -�_7a -- BUILDING PERMIT ISSUED -------------------- _- ---_ `I. - `'-----DATE ADDITIONAL COMMENTS ----- - ---- f --------------------_---------- ------- --r`�'-------- -- -- - ---------- ---- - ----------- - --- -- VIA ` --- -s-- -------- ------ F _ _.T Final Inspecfion /fl�` -�-- Date r -- SAN,.JOAQUIN 'LOCAL HEALTH. DISTRICT i E. H. 9 1268 Rev. 5M