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i FA OFFICE USE: } APPLICATION FOR SANITATION PERMIT r � Permit No. -----�; ----------- - ------------- ---- � ��_�`�--Jj--- - --- (Complete in Triplicate) This Permit Expires 1 Year From Date Issued Y-? Date Issued _ 7:2-- _ _ _ _ ------- -- --- ------------------------------- --_ Application is hereby made to the'San Joaquin Local'NHealth District for a permit to construct and install the work herein described. This application is made in compliance;with County':Q'�dinance No. 549 and existing Rules and Regulations: J013 ADDRESS/LOCATION - }��7/ ---------- I z`" ---------------------------------------CENSUS TRACT -------------------------- JOB ADDRESS/LOCATION Name _: � l LZ_d?r' I I �`�/� � � 1_ / -------Phone -------------- --------------------- Owner -----------------------�<--------- -_ Cit ' --------------------------------.._.._..-------------------- Contractor's Name -------a 71-_-- � -' 1� ,�- License # ---- Phone -- -�--------- ------- Installation will serve: ResidenceApartment House❑ Commercial :E]Trailer Court ;❑ Motxlr'�Other -------------------------------------------- - s Number of living units:___'4-----_ Number of bedrooms ---Z------Garbage Grinder/'-- .___ Lot Size -------------------------------------------- Water Supply: Public System.and name _ _ �_ 1 r� - �� -----------��f��----------- --------------------------------------------------------Private El, Character of soil to a depth of-Veet: Sand b Silt E] Clay E] Peat E] Sandy Loam ❑ Clay Loam :❑ ,Hardpan ❑ Adobe Fill Material __&L If yes, type ---------------------------- (Plot plan; showing size of lot, cat on,6f system in relation'o�wells, buildings,.etc, must be placed on reverse side.) r`« N, ` NEW INSTALLATION:f- ,(No septic tank or seepage pit permitted if public sewer is avarlable-within200 feet,) PACKAGE TiEATMENT [-]-' SEPTIC TANK�[,�` n Size___ --- -- e�_��- -- -------------- Liquid Depth ___ T-Z-----------_.____.__ X Capacity --------- Pe { Compartments v-4 Distance to nearest: Well. -------------- ___ _ Foundation ___v____ -------�?Prop, Line -5__________________ LEACHING LINE No. of Lines _______ _'�_' �� Length of each line_.__-___ ---------- [ - -- ------ ------ 'total Length ` - D' Box/_ _ 'Type Fiffi `K/ilifi�rial ------------------------- --— Filter Material ...__-__._ Distance to nearest: Well ______________ - Foundation ----------- Property Line. �-------------....... � 3 ' _ Rock Filled YesV1 No SEEPAGE PIT [ j Depth _��------------ Diameter Number __.__-_ _____________ ___ t Water Table Depth ------------- Rock Size _/./? ---------------- ------------ � J -- --- _Distance to nearest: Well _ Foundation �--`�__________ Prop. Line ____________ ___ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date '-----------------.--____________--) l Septic Tank (Specify Requirements) ------------- ------------------------------------------------'-------------------------------------------- ------------- -----•------- I - `r Disposal Field ,(Specify Requirements) ----------------------------••-------------------------'-`------------------------------------------------------------- --------------- - --------------------• ------------------------ aI ----------}---- -------- (Draw existing and required addition on 'reverse side) . I hereby certify that I have prepared this application and that the work will be don--eld accordance wit"an 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: "I certify-that in the performance of,thework for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's ompensation'luws of-Califo�niis." ' - 1 Signed ----------- -------------------------------;- --------------------------------------------------- Owner By --------------------------------------------- t - Title _!-r! ----- --- -------------- (If other than own DEPARTMENT USE ONLY APPLICATION ACCEPTED BY f{ ---------n---------------------------------------------------- DATE ----- 5=_ l-'�------------- BUILDING PERMIT ISSUED - ---- -- ---- --- ----- if----------------------- --- ----------- -------DATE ---------------------------------------- ADDITIONAL COMMENTS __________ ----------- --------- - - - ----------------------- -- --- - ------ ------------------------------------------- ----------------------------------------------- Final Inspection by: ------ - --------------------------------------•----- ---------------------------------.Date ------------------------1_ N JOAQUIN LOCAL HEALTH DISTRICT y E H 9-- IS 6B'Rev, 5M. ` �