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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT a --------- ------------------------- Permit No. 3 (Complete in Triplicate) -------------- This Permit Expires 1 Year From Date Issued 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 Cou nty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCA N '`f - ------------ -.--CENSUS TRACT ------------------ r # J� @ _-Phone Owner's Name - --- - -. _ . Address f 1 �-- r ---�W_` +�---------------------------- ----------------------------------- Contractor's Name ------- -------------* --- - ---�i---- �----------._---------License # f '� ,�---- Phone _` Q�---•-- _. Installation will serve: ' Residence-7flApartmennt House-E] Commercial :❑Trailer Court ;❑ } Motel ❑ Othee,1_- - --------------- S r Number of bedrooms _____ __Garba e Grinder Lot Size ____________ _� d___.__...________ Number of living units:_._ J g. Water Supply: Public System and.name-- ---------------------- ----- J--------Private E]Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ ,Peat❑ Sandy Loam ❑ Clay Loam ❑ H�dpan Adobe' ---yiII--Material ----- If yes, type ---------------------------- (Plot plan, showing size of lot, location"i f syst'e'mlin .felation to ells buildin�etc. must be placed on reverse side.) '-� II NEW INSTALLATION: PINo septic tank or seepage pit permitt6d'W-,_puMic sewer is available within 200 feet,) E , t � ._.�__ i 7 e PACKAGE TREATMENT [ ] SEPTIC TANK'[ ]&IS/IMM Size--l------------------- -----.- Liquid Depth -----------.-------------- ,fCap ' - ala ` acil ---------------------TLYpe r___________ - ilNaterial _w OQ _ No. Compartments __ ...___..___..._ Dista41 1 nce to nearest: Well p44.��(_G�__tN __y__'7_ Foundation _.____-_____________ Prop. Line ______________________,/ r !" LEACHING LINE [ ] No. of, Lines _----------- sl ength-of-each-line----------- ----------_____ T&ff17Length -----------------------------:-S� D' Box ------ Type Filter M&terial --------------------Depth Filter Material ---_ ----I------_---------------_--------- tDistance to nearest: Well _____ _____ ___________ Foundation ------------------------ Property Line. _______--_._-_____._....� SEEPAGE PIT [ j Depth A------- Rock Filled Yes No _ _ -� _ _ �D a'mefiet ---------------- Number ❑ I] --- - --- -- - ---- Wa'ter Table Depth - I--------------------------Rock.Siie ---------------- i % t y` `4. __Foundation Pro Distance;taarest: Well1 - p. Line / REPAIR/ADDITION(PreJ Sanitation Permit# ------=------- ----------------------------- Date ---------------------------------- I i.# s -- ---------------------------- --------- Septic Tank {Specify Requirements) l ------------- ----------- ✓O - Disposal Field (Specify R quirements) `"`�'-- ZKQr---1A 1 '` '� -- --------I----,----------------------- -------------- --- �. -------------------------------- -----------' f------ r Y ' f4�"t'�----� --- -- --------------------------------- -----------------------'---------------------------------- (Draw•exis`in and ree- kquired addition on reverse si e) # r I hereby certify that I have prepared this application and that the work will be donejn,�accordance with San Joaquin County Ordinances, State Laws, and Rules and`Regulations of the San Joaquin Local I health District. Home 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 knot employ any person in such manner i as to become subject to Workman's Compensation laws of California." Signed Jht ___ Owner BY ------------------------ Title --------------------- -------------------- - (If n owne . FOR,DEPARTMENT USE DNLY n APPLICATION ACCEPTED BY ____ --�_-- �--_ - ---G'" - ----'"� ---�-�'=�`-'--------------�1------------------ DATE _.__ —�� .7.�------------•--•-=---- ' BUILDING PERMIT ISSUED --- ------ -- �'`, l�s -1V�'. ''_p=4]s`+---------------DATE -------------•----------------------------- k ADDITIONAL COMMENTS -- --______.______________._ __ r - -, ------------------------ --- ------------ --- -- -------- -- - -- --- --- ----- ------------------ a - - ------ - -------- , �. ------------------------------- - ---- -- ----- -------- - ----------------------------------------------- - Final Inspection by: ------- - --------- --- -- --- - ---------- --------------------- Date �v SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'fi8 Rev. 5M