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FOR OFFICE UtE: »z APPLICATION FOR SANITATION PERMIT �} .-f Permit No. (Complete in Triplicate) --------- --------------------- j' This Permit Expires 1 Year From Date Issued Application iseherebymagile to the San Jioaquin Local Health District for a permit to construct'and install the work herein described.- his application is rndde•in compliance with County Ordinance No. 549 and existing Rules and Regulations: ZI S/ I' k -CENSUS TRACT _-_ __ JOB ADDRESS/LOCATION ._ Phone Owners Name --------------- City _. --------------- - Address - r- ------- -- --- ------------- } # f��a y3U; Phone, --------------•----------_-- Contrdctor's NamkI [ --------i_.License # Installation will terve: Residence Ap"�rtment House❑ Commercial ❑Trailer Court ❑ �, i t Motel ❑ Other --i--- -- - --•Garbs f.. J ` � ��, � r------- Lot Size -----Q--------=-------- ------- •----- , Number of:laving--units:•___.-E„_,__ Number of bedrooms -______ age Grander i - - 1.' ', = Private Water,supply: Public System and name -----------•--------- - r Character of soil to-,a depthof'3�feet: Sand'❑z Silt[] Clay ❑ Peat❑ Sanely Loam ❑ Cla \Loam N - e e T- t: � - Y �- Fill ateriaf_ -- ___” f y ,tYP Hardpan ❑ it Adobe'❑ a' 11 s �- { t (Plot plan, showing size of lot, location of system inrelation to:wells, buildings; :etc. must' be placed: on reverse side.) + a> NEW INSTALLATION: (No septic tank or seepage pitipermitted4if!public sewee,'is available within 200 feet,) a SEPTIC TANK11 , i -'--- ------ Liquid Depth _` PACKAGE: TREATMENT [ ]u, l [ ] f Size_- Mater ---------------------- Capacity ., Ca acit ------------; Type ---- - --------- - ial--- - ---- --- No. Compartments 6 x: w.p Y ,. _ t y � Prop. 1`ine -----------• - --- 5 Distance to nearest: Welt---___ _______________.,;,_____.Foundation,:_ -T LEACHING LINE [ } No. of Lines __ Le gth of each line �. II lin --+_- sl-----------------• tal Length : ---------•-•--------- D'>Box -___ - TY'pe ilter Material al eptFitter Mater i i - - - ------ ------------------------------ s , A t �` � � Distance:to�a rest:4;Wi - -----_ Foundafi,ior `;--- ------- Property Line. ---------•-------•- « "' Rock Filled Yes ❑ No i❑ SEEPAGE PIT. �. ) Depth -------------- ---- Diameter Number - ------ ----;---t i Reck Size'' - ------------- Water Table Depth -]_ -----------�` - R----------- ;5 = 1 � .� . 3 Distance to nearest: Well ------- -----• -----Foundation ----------- ------ Prop. Line __.----_-------••-•-. Date- .___, = _ 1 ' �. REPAIRJADDITION.(Rrev,-Sanitation-•Permit-# ---I=- --f----- ------''----- ----------- D 'P Septic Tank (Specify Requirements) ____:__- CAS'.;----- � �-------- 7—� 1 4 ______ r Disposal Field (Specify Requiremen✓��'[�1.�17-'__---I�---�-'-; � �J..�`_- FOOT-- - - s --------------- ---------------------------------------------------------------------- --------- _ - 4 (Draw exition dncl'�equ�red addition on reverse side) I hereby certify that 1 have prepared this application and-thatf�ihe;wdrlc will be done in accordance with San Joaquin k County Ordinances, State Laws, and Rules an#d Regulations of,the:San4oaquin Local Health District. Home ownef or lieen- sed agents signature certifies the following: l'll [*' "I certify that in-the performance of the work;for which fihispermit is issued, 1 shall not employ any person in such manner as to become_s�rb'ect_to.Wo an',s- Compensation laws of California." - - �. Owner Signed .. -y.� }_w I� Own - '----- Title ----- -- ------- ------------------------------------------------------- i (If.other,than.,owner} LAI FOR DEPARTMENT USE ONLY + I� DATE - _� ' ----------------- APPLICATION-[ ACCEPTED BY ------moi ----- ---- --------------------------------- DATE . �_.•`•. - .. -- -- ---- -------- ADDITIONAL COMMENTS r ------ = ,� ,yr"- --- ---- --- - u - - �� ii ------- --------- ------------ I Final Inspec ?!l ------ ---- --------�-�--Date ---.• - I SAN �E OAQUIN LOCAL HEALTH DISTRICT r E. H. 9 1-'68 Rev. 5M. i