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r FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT permit No: ---- : r - - -'---' (Complete in Triplicate) _Io1' I Date Issued ---------- ------------- This Permit Expires 1 Year From Date Issue it to construct and e work herein rict for a p Application is hereby made to the Son com liiin eJoaquitim cwial Hh Counealth ptytOrdinance No. 549 and existing Rul.estand hRegulat ns. described. This application is made r p r ., " ------- _._-CENSUS'�TRACT _"__--_.___7-- JOB ADDRESS/LOCATION -4 IC-75-�J �� T -- Phone A ISA- !7 �0�6 5 Owner's Name ----- - �gJ� ------------------- Address ------ - --------_26-6c- -----1 f �' k Pone --- -----------------------------------------License # Y Contractor s Name _-e21_tfvv '' > Installation will serve: Residence ❑ Apartment House-E] Commercial ❑Trailer£ t �w f k Mote! E] other ----------------------------- --------- Garbage Grinder/, 1ILot Size Number of living units:_-_----- Number of bedrooms ___-___"____ g �. Private ------------- Water Supply: Public System and name ------------------------------------------------------ ---------------------------------- k ; .f f•:9 ( Clay Peat❑ Sandy Loam ❑ Clay Loam FORMr= s Character of soil to a depth of 3 feet: Sand'�ilt❑ Y 0 � -POMP� i T Hardpan ❑ Adobe ❑ Fill Material -- If yes, type - . buildings,�etc. must be placed on reverse side.) (Plot plan, showing size of lot, location of system in relation -to wells, NEW INSTALLATION: (No septic tank or seepa. it permitted if u lic sewer is gvdilable within 200 feet,} p -------------- SEPTIC TANK:[ s' --- Liquid Liquid Depth -------- PACKAGE TREATMENT [ ] Size' Material CON No. Compartments -------•---a---- Ca Capacity �7�D--- TYpe k —�F- i -+ _ Foundatiori ------------- Prop. Line . Distance to nearest: Well ---- -'- --- LEACHING UNE _"- -----.7,0---- - Total Length o. of Lines --------- Length of each line 'D' Box \IAE:71_451. Type Filter Material RO_� ___Depth Filter Materia! ___--f� p " �-i---- Fountdation __LQ_f--- Property Line. --------- --- - ------ Distance to nearest: Well ---- �-"-- SEEPAGE PIT [ ] De{ th� Diameter ----------- Number - Rock Filled Yes © 'No 1� N/at�r Table �Depth ------------------------------------- Rock Sizet .Foundation --------------- ---- Prop. Line ------------ ---•----- Distance to nearest. Well __________________________ _ rDate -----------1 f REPAIR/ADDITION(Prev, Sanitation Permit# -------------------------------------------- ----------------- i Septic Tank (Specify Requirements) -------------------------------------------------------------- ^' {] Disposal Field (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, state Laws, and Rules and Regulations of the San ,Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: p y person in such mannev "1 cerci in the performs e f the work for which this permit is issued, I shall not em to any i as to subject to Wo a 's pensation laws of California." Owner , Signe ? *-�. -e ' �" Title ------------------- ------------ - ----------- y ! $Y -------------- --- "----"" "-(lf other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY._-----!--R-v------------------- -- ---------------------------------- � BUILD.lN_G PERMIT ISSUED _-'---------------- -'------ -'------ ------- - ------ ----------'---- -- ---- --------- ------- -----:DATE ------------------------------------------- BUILDING ----•-'------- ------ ----------- ADDITIONAL COltil MENTS=_�_- _-----=--- r _ ------- ---- -- - ---------------------------------------------'---- _ - T _ - - - - - - -------- ------------------------ ---- " - - _ - ._ - ;� - - ---------- --- -' - ----- �� -Date ------ -- nal In G Final Inspection ---�- "" - SAN JOAQUIN LOCAL HEALTH DISTRICT r- u 0 1_'AA Rev. 5M