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r FOR OFFICE USE: APPLICATION FCrR SANITATION PERMIT << Permit No. _. �`------- ------- --------------------------- ------------------- (Complete in Triplicate) . ___ ------------------------ 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 Ordinance No. 549 and existing Rules and Regulations. _ �!� Q'�-O?�y.._ C_Qi�.i ,:-_ g�',' --CENSUS TRACT JOB ADDRESS/LOCATION _._-�_�-��----�- ------- - 4i� .] Owner's Name ------- --------...'- -- -------- ----------------Phone -------- - ---- - ---•- --- Address ------ --71-`�' _3------------ � f` r--------- - -------------- city ------- C2- 1 Contractor's Name ___�i1_I _s°_. a.��- -------5-,e-a I'C----1 5-----.License # ---Ul_(F�_�_ Phone _ -"--- .If Installation will serve: Residence R Apartment House❑ Commercial []Trailer Court ;❑ Motel ❑ Other -------------------------------------------- Number ------------- ----------------------------Number of living units:-----I____ Number of bedrooms ---4___..Ggrbage Grinder _ e,5- Lot Size TZ Water Supply: Public System and name --------------------- Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam .[ Clay Loam ❑ Hardpan Adobe ❑ Fill Material ----------i- If yes, type ---------------------------- (Plot 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 public sewer is available within 200 feet,} %Q i PACKAGE TREATMENT J ] SEPTIC TANK'D4 Size_ ��J.�- f ------- -------- Liquid Depth ---- ------------ .__:_�....------. Capacity 160----- Type �urt"____ Material Cax► Cat-� No. ompartments O Distance to nearest: Well --------ZQ--------------- Foundation _1,0---_-_------- Prop. Line ----• -.----------- a6 -/ ---_--_____ Length of each line__� p------------ Total Length _______ LEACHING LINE � No. of Lines -___.-- ,� Depth Filter Material _____1 -----------------------•---------- 'D' Box ___/------ Type Filter Material ___�__ ____-__ p Foundation --- -_off-- ------ Pro er Line --,. .� ------ Distance to nearest: Well __/, -p___------ p �� .� SEEPAGE PIT &I Depth ____��_____- Diameter ___ __-________ Number __________ _________�f/Rock Filled Yes � Na � f � Rock Size -------------- ---------------- Water Table Depth - ---------- 11---------------------------- � f Distance #o nearest: 1NeII 1 r _--------------------Foundation __� 4?_---- Prop. Line _.. __.�_--_____._ REPAIR/ADDITION(Prev. Sanitation Permit# ------------��-------- ------------- Date ----------------- ---------- - -------------------------- Septic Tank {Specify Requirements}<-------- ----- -- ----- ------ -------------------- Disposal Field (Specify Requirements), ------------------_--------------------------------------------------------------------------------------------------------------------- -------------------------- --------- ------------------------------------- _ --r------ x -- -- -- li ation and that the -- (Draw ei in and required addition on reversee stside) I hereby certify that I have prepared this app ' a 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: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ---------------------------- -------- Owner BY -- ------- - ----=--------- Title (If other than owner) FOR DEPARTMENT USE ONLY ' ------. DATE ---��-i.---_.__ �----/----------- -- APPLICATION ACCEPTED BY -c�.-�Z- ------------------------------------- --- - --------------- BUILDING PERMIT ISSUED ----- ---------------------------------- -- -----------DATE ADDITIONAL COMMENTS ------------------ ---------------- ----------------- ------ -------------------------------------------------------------------------------------------------------------------- ------------------------------------------ - -- ------ ----------------------------------------------------------------------------------------------- -----= `� ----------------------------------Date ---------- ---- ------- Final Inspection by. - -- - -----G=- - -- -- ------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT r W 0 1.'AR RPv_ 5M