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FrJR OFF` E USE. APPLICATION FOR SANITATION PERMIT - Permit No. -----------------•--- .,� ---------- (Complete in Triplicate) �- DaterIssued ---------------- This Permit Expires 1 Year From Date,ssue Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein Pp This hereby is madelin compliance with County Ordinance No. 549 and existing Rules and Regulations: described. Th pp /'t =f- CENSUS TRACT 7�i p �r � _ f9 � ........... 4 JOB ADDRESS/LOCATION ._ 1 f I � - Phone_ _ _ - �1. Owner's Name ��ri!� (, Sr _�fi_4i_a '- S'�� ✓ ------------- --------------- - Cit ----------- 17 --------- tix 1e. � -mss--------- ------------------------- v Address ----- � 6Q. ----- ---- ----- - --- -- � ,�/r----- Phone,: :-:-- ------;. Contractor's Name ------------- -- t _ -----License # , Residence`p[Apartment House❑ Commercial []Trailer Court `❑ ' installation will serve: ' I Motel ❑Other ------------------------------------------ 2d` i ------------ its; r ; Number of living units:___[-_____ Number of bedrooms - _-_-Garbage Grinder _____-____---------------------------------------------- Lot Size Private' Water Supply: Public System and name ------------ Peat❑ Sandy Lm ❑ ClaywLoam ❑ Clay � Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Y e - Hardpan ❑ Adobe` ] Fill Material __-__--_--- ifs,typ (plot plan, showing size of lot, location of system in relation #o wells, buildings, etc. must be placed on reverse side.} I it permitted if public sew is available within 200 feet,} �r NEW INSTALLATION: (No septic tank or seepage p p r �� Liquid Depth _. `--------- PACKAGE TREATMENT I: ] SEPTIC TANK ¢Q Size_____-- --=.1--� �ZEc , _-_ Matetlal__Ciwr -=--- No. Compartments Capacity f h_ Type - r � r # .------ Prop. Line .._- -- Foundation ------- , Qistance to nearest: Wel{ -------- ---------x _�^� ""- ------- Total Length __1- _0. LEACHING LINE '�Q No. of Lines ___-ly----- ----- Length fof each line-"'-�� - ;- �t D' Box -.---(/ TYpe Filter Material __R_Q49-----Depth Filter Material -----� ' :: F �- @ r`� Pro Proper- Distance'! a ----^� ... f Distance! nearest: Well _--�D --------.Foundation ----�---- � p � � �� .E t = ;-�Rock,F.ilVed .Yes `� No Depth - Diameter � 3,".t ';.Number - _SEEPAGE PIT �Q P s x ; � ------Rock Size --- �r---L-------------'------ � Water Table Depth - 6 '` L ---.1 4 _. Line ----•---- - - ation-- --- �Pf OP. Distance.� oFnearest: Well ------ - < :} f =' Date ---------- ------------- ------1 j' REPAIR/ADDITION(Prev. Sanitation Permit#-•---__- �� -_-----_ k ' --------------------------- Septic Tank (Specify Requirements)'---- ---- Dis osal Field (Specify Requirements) ---------•----- ----------------------------- - ------------ ---- --------------------` ----------------------------------------------------- --- --- -------------------- - -------------- (Draw existing and required addition on reverse side) ne in acco Thereby certify that I have prepared thui is application and that the San Joaquin LocafoHealth Distridct�Ho a Owner or Ice with Son cenn County Ordinances, State Laws, and Rules and Regulations sed agents signature certifies the following-- serson in such manner "1 certify that in the performance of the work for which thipermit is issued, 1 shall not employ any p k i as to become subject to Workman's Compensation laws of California•"------- Owner- , v Signed - - --- - - - --------- ----------- ------ --------------- J itle -- Y (if other than er} FOR DEPARTMENT USE ONLY -7 DATE APPLICATION ACCEPTED BY - ------ - ----- DATE -------------- BUILDING PERMIT ISSUED --------------------------- _ - ---_--- ------ = ---- - --------------•----- ----- --- - --- ----__ ADDITIONAL COMMENTS ---------------------- �� ---, ------d ----------�= - 7------------ ------------------------ ------------ ----------------- # c� - � ,. . ------------------ 1-__� Date _. . ------------- ----- ------------------------------------- Final Inspection by: ------ ----- SAN J AQUIN LOCAL HEALTH DISTRICT u o 1_'AR Rev. 5M