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FOR OFFICE U E: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. �=,( / I This Permit Expires 1 Year From Datelssued Date Issued I----------------------------------------------- -- 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 compliant it Count Ordinance No. 549 and existing Rules and Regulations: t M JOB ADDRESS/LOCATION . ------------------- ENSUS TRACT-------------------- Owner's Name / - ----- -- e W --- ---- --- --Q ---- _" ... Address -�L l -- ------'� /------ ----- - - Cit ----- v Contractor's Name _-_----- -- --------- ----------------License # - - 1� -- Phone�4 -- ---- -- - ------ --- / 6- 6D ' Installation will serve: Residence KApartment House❑ Commercial❑Trailer Court ',❑ Motel ❑ Other -------- ----------------------------------- / Number of living units------ ----- Number of bedrooms __-_>�Garbag Grinder _______ ---- Lot Size -_--oQ-- Water Supply; Public.System and name _____________________________ Private y ❑ Character of soil t�'epth of 3 feet: Sand'❑ Silt❑ Clay Peat❑ andy Loam:F-] Clay-Loam ❑ .� Hardpan ❑ Adobe Fill Material - `-if ye's, type ---------------------------- (Plot plan, showing size of 11ot,- location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: {No se tic tank or seepage,pi#`permitted if public sewer is available within 200 feet,} v PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] size-_--:-.---A-----------------------------------= Liquid Depth -------------------------- . r �1 Capacity ----------------------Type -------------------- Material--------------------- No. Compartments ------------ ----- Distance to nearest: Well _-- -^!--------- ------ati�o�n -•--------- ---------- Prop. Line ---------------------- I --_.--.- ------ �Jr LEACHING LINE [ ] No. of Lines .------------------------ Length of each line-_ - --------- Total Length _--------------- 'D' Box --- ----!--Type Filter Material ----------- --------Depth `Filter Material -------------------- --------__--------- Distance to a est: Well - --------J------------ Fo'ndati on -------It--------------- Property Line -------------------:---- SEEPAGE PIT [ ] Depth Diameter _ _____________ Number . fi F__._.._____.__ Rock Filled Yes [] No :0 �,- . Water Table Depth -------------------------------------- --Rocb Size '--- ' Distance to nearest: Well .-------- I---------------------------Foundation ---_.----�-------- Prop. Line ---------------------- REPAIR/ADDITION(PrevrSanitation-Permit-# ._-__-_-- ---------___________________-_____ Date ________i_____________i______-_-} Septic Tank (Specify Requirements) -- -- ----h-FRti r"------ ----------------- ------ ------------------------ --------------------------,---------- Disposal Field (Spi cify Requirements} _=-...t=_ -- ---------------------------------------------------- ----------- - - i •:. , 11 t r - ------------------ -- - ------ =� - - .__.____- __ --------- ------------------- �I_. _____ - _. - ----------- ------- Draw existing and required addition on revelse de} I hereby certify that 1 have prepared this application and`rtliat4the work will be done inaccordance with San Joaquin County Ordinances,-�State�Laws, and Rules and Regulations o.f.the.San--Joaquin local Health District. Home owner or licen- sed T i sed agents signature rtifies 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 Workman's Compensation laws of California." Signed ------------------ - ----------- --------- - ��. ---------- -------- Owner BY --- - --- f ----------------- ------------ Title .-------- ------------- ------------------------- If r Pi 94 owner] EPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ .- -- ---- .__---_---------- ----------------- DATE -----f' BUILDING PERMIT ISSUED ------- ` - - - ---- ----------------------- -------------------DATE ----- ------------------ ----- ------- ADDITIONAL COMMENTS ----- --- --- -- ------------------- ---------- k _ f ------- ------------------------------------- ------ --------------- - Final Ins action b -Date ___.__-_ __- p Y � r� r7 � / ---------- SAN -- -SAN JOAQUIN LOCAL HEALTH DISTRICT (/ E.,H. 9 1-'613 Rev. 5M