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I FOR OFFIC USE: APPLICATION FOR SANITATION PERMIT k ; ------------------------------ .� (Complete in Triplicate) Permit No. ._____---------------- - --____. 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 County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION --- !'�� 1 �`� f= 5------�5EXTI-JQ... ---------)P-_ '-------------CENSUS TRACT ---4--------•----- - Address Name L�_:f�.�_t:��-:��-!�R_�1=N_�-��-=----------- Phone -------------- - -- A. *1- S = R!/ City __MoD_t�ss r ------------------------- ---------- ------------------- Contractor's Name '------___ ___ -------------------------- ---------------License'# --------------I---------- Phone ----------------------- Installation will serve: Residence Rr-A--partment House,[-] Commercial:❑Trailer Court ✓� --%� -- _J.T._._--.Motel-❑Other ------------------------------•------------- Number of living units:-----t----- Number of bedrooms -3------- Grinders Lot Size tB-fC-T --------------- Water Supply: Public System and:risme C`��t�t-3 ) -------------•------ - ------------------------------Private Character of soil to a depth of 3 feet: Sand'Silt❑ Clay ❑ Peat❑ Sandy Loam '❑ 'Clay Loam ❑ .Hardpan i a era _ = e�:, _a- ❑ Adobe M t I-[IIC? _- If yes, - {Plot plan, shawirig size of lot, location of'system in relation to wells, buildings, etc., - ust be placed on reverse side.) NEW INSTALLATION: (No—septic tank or;seepage pit permitted if public sewer is o cfilable within 200 feet,) PACKAGE TREATMENT [ SEPTIC TANK Ic Size__ �,� [ 6 •l 1 Liquid Depth / z--� . {\_ Capacity __/6_OCeCF� -__.__ Typ �g Material__�1V-C�---- No. Compartments ---_ - --- istance to nearest: Well ------4�r----t--------------Foundation -_l�_---+------- Prop. Line -_•.�~_-----�... . ---- Total Length LEACHING LINE [Al"_� .., I Z � � - �''----- No. of Lines __. ._-___.___'_.__ Length ofline-/7 each _-7` _____ ------ SD -� • v r D' Box �'_ 5__ Type Filter Material �pG_/i___,-_Depth Filter Material f -• Distance to nearest: Well: -.____----------______ Foundation __.-_--_- _-119--- Property Line ---------------- SEEPAGE PIT [ ] Depth Diameter ---------------- Number --------------- --------- Rock Filled Yes ❑ No .i❑ Water ITable Depth -t --------------------------------:7 Rock Size---------- .-.------ Distance ----Ditante tornearest: Well :--;-------------------------------------Foundation -------------------- Prop. Eine-, 77 REPAIR/ADDITION'(Prev. Sanitation Permit#_.__:'__:4__________________ >_--_-______-t_ Date Septic.Tank (Specify Requirements) --------------------------------------------- ••- -----_— •-- Disposal Field (Specify Requirements) _ -------------------------------------------- ! --- .___________ ___ i A . -------------------------------------------- t F I 1 7 (Draw existing-ond rec{uired addition on reverse sidej � --•4- Y �. I hereby certify that I .have prepared this application and that the work will be done in accordance with San J6aquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin''Local Health District. Home owner or'licen- k sed agents signature certifies the followin _ "I certify that in the performance of the work-for which this'permit is issued, I shall not employ any person in such rnpnner as to become subject to Workman's'Compensation"laws of California.,' Signed - J�- Y7_1�X7------------- ------------------------------..,Owner , BY ----------------- ---- Title -- --- - ---------------------- ? (If other than owner �o � IT E Fdk, DEPAR ENT USE ONLY q APPLICATION•ACCEPTED BY -------------- _ --------- --------------------------------- DATE ------ BUILDING- -.- ADDITIONAL ...._.� / COMMENTS y : - - __________ _________ ______ ---------- _ __ - ____________________- ------------------ ----------------------- ----------------------- -----------------------------------------------------___-_-_-_____-_-_--___._.--_---_-_ •_ - __ ___• - - -- --- --- • ---------------------I _ _ _ Final Inspe ---- ---------------•-------------- --__ _Date ---- SAN JOAQUIN LOCAL HEALTH DISTRICTv E. H. 9 1-'68 Rev. 5M i