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x `FORIFFICESE: APPLICATION FOR SANITATION PERMIT Permit No.----•---------- ---- ----------------- (Complete in Triplicate) ' Date Issued `�� This Permit Expires 3 Year From Date Issue Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No.. 549 and existing Rules and Regulations: ` __CENSUS TRACT ------------------ JOB ADDRESS/LOCATION --��---f- --- _--'�--�'-f-sr ��'��"1� - - --------- ------ - �s'f ------ Phone Owner's Name ----- 'L'° - ��---------- -- Address ----- ----- ------ - -- � - - - - '----- -•------ -------- - ---,.,�� City Contractor's Name ______---_ r�� �,/ 1f -----_.License # __ Phone �r Installation will serve: Residence (] Apartment House-E] Commercial ❑Trailer Court Motel ❑ Other -------------------------------------------- Number ------------------------------------------ / / 2 ____--_Garbo a Grinder - Lot Size Number of living units:_` _---- Number of bedrooms , 9 Water Supply: Public System and name ______________________ _ ------ ----------------------------------------------- ---------------- Private Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam:❑ Hardpan ❑ Adobe-F-1 Fill Material ------------ If yes, type ---------------------------- n to wells, buildings, etc. must be placed on reverse side.) {Phot plan, showing size of lot, location of system in relatio NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ Size-----------------------------------•----------- Liquid Depth ----------------- SEPTIC TANK'[ ] ------------ No. Compartments -�-------------------- Capacity -------------------- Type ----------------- Material p , Distance to nearest: Well ---------- ---------------Foundation ---------------------- Prop. Line -------------•----• ------------------------ Length o0each line---------------------------- Total Length ------ ---- LEACHING LINE [ ] No. of Lines 'D' Box ----- Type Filter Material ---w----------------Depth Filter Material ------------------------" - � Distance to nearest: Well _______________" -------- Foundation ------------------------., Property Line I Number ---------------------------•Rock Filled Yes C] No i0 SEEPAGE PIT [ ] Depth -------------------- Diameter ------------ WaterTable Depth -'---------------------- ----------------------Rock Size -------------------------------- k Pro . Line -----------------•---- Distance to nearest: Well ____________________________""_-- _____._Foundation _"""----.------••-- p• -- ---------------------- Date -----------------------------r---) ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ------- - Septic Tank (Specify Requirements) --------- - t --------- -------------------- ,.. --------------- -- Disposale-Field (Specify Requirement ) ---- % �- � � --- F ---�--------------- ---- ` '-. �' --- .} ��---r------------------ = j ----------------------- ------------------------------------------------------------------------------ ----- ------------------------ #� (Draw-existing and required addition on reverse side) 1 �''k I hereby certify that I have prepared this application aone in accordance with San Joaquin nd that the work will be d County Ordinances, State taws , and Rules and Regulations of the San Joaquin Local 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 not employ any person in such manner as to become subject to Workman's Compens n laws of California." i Owner Signed - ---------- --------- ---- - ------ ---------------------------- (CI ------------------------ Title (If o� an owner R FOR PARTMENT USE ONLY r ------------------------------------------- DATEDATE ----`�- � �(-------------- APPLICATION ACCEPTED BY ___-- BUILDING PERMIT ISSUED ------------------ -------------------------------------------------------------- ------------------------------------- ADDITIONAL COMMENTS -------- ________________________________________________________________________ ____________________________________________________________ . -------------------------------------------------------- , .__I --------_____.__ __ _ __ _______ - // --------------------- Final __-____ - x Date--------------------- ---------------------------- Final Inspection by , SAN JOAQUIN .LOCAL HEALTH DISTRICT „ n_.. CAA