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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: (Complete in Triplicate) ------- --•------ ----------------------- ._._�- Date Issued ___-----___- This Permit Expires 1 Year From Date Issued Application is hereby made to the anJoaquinLocal Health District for a permit to construct and install the work herein described. This application is made in co idi pceWCountOrdinance No. 549 and existing Rules and Regulations: �` f - K"'.`--ENSUS TRACT ------/0 ADDRESS/LOCA�TIO* N . i[�rs-: - .-©---&I 7.4'�'-- �4 Owner's Name ------e-`�-------------N— - --->/ Cit - Phone Address ------------------ - /U-- � n ---------------- --------- Y j '� f---------------------------------- 5 - Contractor's Name -��- . [-C:- 1 - -------.License # �`^ Phone � Installation will serve: Residence U-A'�cirtment House-D Commercial []Trailer Court ',❑ Motel ❑Other ------------ ------------------------------- Number of living units:----t------ Number of bedrooms 3------ Grinder J�b Lot Size -------------------------------------------- Water __ ----____-------------------------------Water Supply: Public System and name --- ---------------- - -------•-- - ---------------- ------------------- ----------------- ---------- Private ❑ f- Character of soil to a,depth of.3 feet: Sand'p,-'ilt:❑ Clay- ❑ Peat El . Sandy Loam -❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ------------------------ (Plot:plan, shyowi.nga.size�.ofAlot, location-of-system in relation to wells, buildings, etc, must be placed on reverse side.) i a'• � A. tel•. ...—...6 NEW INSTALLATION: (No septic tank or seepage4_'p�t'permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT I I SEPTIC TANK'[ ] t Size-----------------------#----------- ----------- Liquid Depth -------------------------- .%r$ t Capacity - ----- --- -- Type Material No. Compartments Cn1 Distance to nearest: Well I ---Foundation __.-- - Prop. Line ---------------------- -------------------- ------------ - LEA.0 4E [4} No. of:Lines VV—Length of each ..-- Total Length _-- - ----------------- 1 'D' Box -.--�--- --- Type Filter.„Material- - qCr 4: ---Depth Filter Material ----- ------------------------••---•--•- r ! � 'yam •�` i � 3 ' ,.:=---” --- Foundation L° Property Line ---I--•----------- - --- Distane to nearest: Well ----S-- l - p tY SEEPAC P1Tj [ ] Depth I---------------- -- Diameter ---- -------'`"`Nur+ ber .--.------------_----------- Rock Filled Yes ❑ No i ,. ---------Rock Size -------------------------------- L....--�-•�---�•--�-�1/ater`Table Depth ---------_ -------------------------- k - tDistance to nearest: Well 4----------------------------------• -Foundation •__ -------------- Prop. Line ----------•----------- i REPAIR/ADDITION(Prev. Sanitation Permit#-----= ------------------------------------- Date ------------ --------------------- Septic Tank (Specify Requirements) ----- e ------- ---- -------------- .- Disposal Field {Specify Requirements) ---------aF--------56 WI-per...... Joc }:---- _ ------------------------- I---------- ----------- -----------------------------------------i-----------------------------------------------------------------I---- ----------------------- ------- ------------------------- --------•--------------- # ------------------------ ---------------------------------- (Draw.existing,.and-required-add itio•n.on reverse si ,e).._.... - . . - . I hereby certify that 1 have prepared.th,ii�applicatlon 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 ownef or lieen- sed agents signature certifies the following: "I 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 Work n's opensation 11 sof California." Signed _ -- - --- ---------- Owner By ---------- --------------- -Title --- - ----- --------------- ---------- (If other than o ner) FOR DEPARTMENT USE ONLY � C/ `G�----------------- ---- �f APPLICATION ACCEPTED BY _.--�-__. ------------------------ -- --- -------- DATE ------ BUILDING PERMIT ISSUED ---------------------- -------- � ------DATE ------- ----------------------------------- ADDITIONALCOMMENTS ------------------------------------------------------------------- --------- -- --------------------- ------------- - - ------------ ------------------- ---- --------- W'.0 ------- - - - -- -------------------- -- ---U;�� ---------- -------------- ---- - ------------------------------------ ---------- ---------------------- --- ---- --------------------------------------------------------------------------------------------------------------------------- --- -------- ---- --- --- --- -------- --/- ----------------- rFinal Inspection . - r ----------------------------- Date 4 `- -------- - - ---- ---- ------ --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M