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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT � SComplete in Triplicate) Permit No. ........ f ................... ..........._......................... ... .............................. This Permit Expires 1 Year From Date Issued Date issued k 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: i JOB ADDRESS/LOCATION1. --.....,CENSUS TRACT Owner's Name T Q57 ...:.... Q..!........................................... , .... Phone ................... Address city } � L > ...License # ........................ Phone Contractor's Name il ..... ... �. .P ...:....J� .......... Installation will serve: Residence MApartrtientv House�ommerciol ❑Trailer Court- a-,•• A .; Motel ❑Other--• � -•................................. ~� Number of living units:--__/--�I.. Number of'bedroor'hs .3._ .Garbage Grinder Lot Size. Q�� _ 1--......J. Water Supply: Public System land narne,�-..^__......................... .-:_.. .................................................... ........Private �� Character of soil to-a de tl of 3 feet: Sand Silt Clay •Peat _- p + '❑. ❑ y ❑ � ❑ ,,��//Saridy Loam Cay Loam �� q Hardpan ❑ J�clobe ❑ Fill Material -..�V.4 If yes,type _-.--_------------------ (Plot plan, showing size of lot, location of system in relation to wells, buifdings;�ett imus# be�plae6d on reverse side.[ NEW.INSTALLATION: (No septic tank or''seep 1 spit permitted if qvblic sewer is available within 200 feet,} �� 1 PACKAGE TREATMENT [ SEPTIC TANK. i Size_Ap........ .....y..................... Liquid Depth P ......... Capacity .� ............. Type — Material.-_ u._. No. Compartments Distance to nearest: Well._-_I ..._. `._.:� _-Foundation + . Prop. Line LEACHING LINE No. of Lines .._...... _'_ Length of each line -I-p----- Total Length .-...17 ........... 6' I1�� d / Q �� p /r D' Box -_ -- ;ype Filter Material B... .-.De th Filter Material 1l..........................:... O nn�� Distance to neprest: Weil_.a...r.-!`� Foundation �1�. r� •.. Property Line .-��J..__`-i- .:. ...... 4... ............. SEEPAGE PIT / De tli1 �_..--... "''�Di meter �,7/ Number -..-------..�---:-. . Rack Fille Yes No ❑ ' a r �� Ir Water. Table Depth// .---:-- i ,........Rock Size �- tn t Distance to neareit: Well 11C,._...__ ...._Foundation A `-!� Prop. Line ................. p' it // REPAIR/ADDITION(Prev. Sanitation Permfit# ............... ..........••............... Date .............. ................. 0 �¢ ;Septic Tank {Specify Requirements} ..............•------•-•--------•-•----•---•--.....•........-----•---• ;67 -•:....-.:..........._... ;'Disposal Field (Specify Requirements) ........................ ---- -- - ----- -- ........................................................ ......•---- -------- ----•---- ---- (Draw existing and required addition on`r6verse,,ifdej4(I g I hereby certify that I have prepared this application and that the work will be done in accordance with Son Jac " County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Horne owner or litett- sed agents signature certifies the following: I 461 certify th th perfo e a e work fo which this permit is issued, i shall not employ any person in such manner as to 6ec a sub ct to mpenso aws of California." Sig -----e ------------ - ----• ....... .... .. Owner By ...........................................•-------------------------------- ..........._...------ .- �...�.•�.---- sills ..-.-_..-.-..-..-.._ Ilf other than owner} FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY1 ` ............./..19`......----•-•---------------------••-----------••--•-•..-........--•- -. DATE ..... ��.._�-S BUILDINGPERMIT ISSUED -------------•-•- -•-- --••-•------ ......................................................=..............DATE .........••--..............- ........... ADDITIONALCOMMENTS .........._... -•--------------- ..-......_ --•-----..........--............--•--................:.......................................... ._. .... �.�.. _._._.,� mow.._- ._.� . R Final Inspection ...... • ........... .............. ....Date ....�.. SAN JOAQUIN -LOCAL HEALTH DISTRICT t E. H.1.3_,241.'68 Rev. 5M 7/723 ,K