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FOR OFFICE USE: r r' LICATION PM SANITATION PERMIT # ---------------------------------- - ` (Coplot ) Permit No: --��J - t ��®_.. .. - �....-� Date Issued --- ----------------- This Permit Expires I Yeal!Fro ate Issued � s. s.s, vs� > , r -��Application is ere y made to the San Joaquin Local Health District for a per to construct and install the work herein . desc;i ed. This ' at, m in com iance with County Ordinance No. 549 and existing Rules and Regulations: AA4`Dr '�" CENSUS TRACT �2G�_��D- O7 JO5 /L CATION -------------------------- ------- ----------------� �----------'-- - � #,+Y Owner's Name --------------�'0_ ----------- //'_J-------- --------- -- ------- - --- -------Phone ----------------- --------------• -- 1;0 Address ---- ---------/----- �C�r'i` city --------------- --- ---------------------------------- .... Contractor's Name _ '•` _ y,:•f .'!s°�----- = F License # Phone . (' Installation will serve: Residence ❑Apartment House❑ Co mercial ❑Trailer Court i❑ Motel ❑Other ----------- -- p gym. f v�Yin n :__. lgiumber of bedrooms __________Garbage Grinder ._____.____ Lot Size ___________________________.______._..____ quaat`e tea. ame --------- ----------- _. __ _ _ .� Private �- - Character of. so'r.l�to.a depth of 3• eet: Sand'❑ Silt❑ Clay ❑ Peat F] Sandy Loam [?$ Clay Loam ❑ Hardpan E] Adobe-E) Fill Material -_._-------- 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,) f Size �--��-----f----------- Liquid Depth .---- -------- -------- i PACKAGE TREATMENT { ] SEPTIC TANK _ Capacity -_.e'----- ; -.--- Type --------------------(Material---- ----- r-_'_�' No. Cpmpartments "-- + Distance to nearest: Well -_________ -3 0________________Foundation --------16) Prop. Line _____----- a r y LEACHING LINE No. of Lines -------------f-------- Length of each line____-- -- - ------.__ -__ Total Length -----_ --• --------- --- ! JJ 'D' Box --- --- Type Filter Material _ -� -- r zr`Efepth FilterMaterial --------- ---•------------•--- -- r Distance to nearest: Well ------��o____-------- Foundation _.____ ---------- Property Line _ ______'__. -- ___ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number -------------------`-------- hock Filled Yes ❑ No i❑ WaterTable Depth --------- --------------------------------------Rock Size -------------------------------- Distance to nearest: Well ---------------------------------------- -------------------- Prop. Line ----------............ REPAIR/ADDITION(Prev. Sanitation Permit# -•-----•------------------------------------ Date ---------------------------------- Septic Tank (Specify Requirements) -------------------------- ------------------------------------------------ --`.--------------- ------------ DisposalField (Specify Requirements) ----------------------------------- ------------------------------------------------------------------------ ----------------------- ------------------- ---- --- ------- --- --------------- ------- ----� - -------� ------ --- ----- --- ---- ------------------------------------------------------- --------------- --- -- - -------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin ' County Ordinances, Stare'Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or licen- 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 Workman's Compensation laws of California." Signed e";"r / �f` i. • i r 'Owner ' l Title -------------------------------------- -------gy - .- ----------------- (If , r other than owner) FOR DEI' RTMBNT USE ONLY � " DATE -- - ,' /11;1 ��APPLICATION ACCEPTED BY ---- - ------------- --=----- ----------------- - -------------------- BUILDING PERMIT ISSUED ------------------------- ----------------------- -------------------------------------------- .DATE ------------- -------- ADDITIONAL COMMENTS ---------------------- f --------------------------------------°-------- ------------------ -------------------------------------------- ------------ --------- ------------------------------------------------ ----------------------- - --------- - ------------------------------------------------------- = Final Inspection by, ------ Dale 7U SAN JO QUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M