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r .> FOR. OFFICE USE: APPLICATION FOR SANITATION- PERMIT Permit ------------------------------------------------ (Complete in Triplicate) ,.,. ------------------------ This --------- ------ Date Issued __f Z ------- ------------- : -------------- I This Permit Expires 1 Year From Date Issue cal e work Application is hereby made deiso the Son complln Loiance witheCounalth DtytOrdinance rict for a No 549 and existing Rulesrmit to construct and talndhRegulatonsrein described. This application �L ®c - - ---- -----CENSUS TRACT - ----------------------------- --- JOB ADDRESS/LOCATION ----- ------------ V __Phone - Owner's Name S*V\ - QA)kr_t,&------ --•--. Cit -----------------•---- ' Address ----- --------- ----- ------------------ --- ---- ------- Contractor's Name ----t,-�-��---- ------------------- - -------------- 'License # ------ -------------- Phone --------------------------• -- Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑ Other ---------------------------------------- --- Number of living units:--I------ Number of bedrooms __ce)--------Garbage GrinderLot Size ---k_:-- -------------------------------• ----------------- -------------- Private[ ; Water Supply: Public System and name -------------------------------------- ----- ❑ ❑ y Peat❑ Sandy Loam ❑ Clay Loam Character of soil to a depth of 3 feet: Sand' Silt Clay ❑ ' Hardpan ❑ Adobe Fill Material ----------- If yes,type ---------------------------- �. (Pl'ot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] O PACKAGE TREATMENT { ] SEPTIC TANK;[ ] Size___----------------------------------- -- Li -------------------------- Liquid Depth p }! Capacity --------------------- Type ---------------- _-- Material------------------ -- No. Compartments ---------------------- Distance to nearest: Well ------------------------------------Foundation -- ------------------ Prop. Line _.--------•----------- -- Len th of each line---------------------- ----- Total Length ---------------------------- LEACHING LINE [ ] No. of Lines --------------------- 9 -------------------------------• 'D' Box ------------ TypeFilter MaterialTYPe Filter Material -------------------- P Distance to nearest: Well ------------------------ Foundation ----------------------- Property Line ------------- Diameter ------- Number _. Rock Filled Yes ❑ No C1 SEEPAGE PIT [ 1 Depth Water Table Depth ----------------------------------- -------------Rock Size -------------------------------- . ------Foundation -------------------- Prop. Line Distance to nearest: Well ___________________________ _ REPAI ADDITION ev. Sanitation,Permit# -------------------------------------------- Date -------------------------•-------- ) �. ----------------------------------------- __... - -------------- Septic Tan (Specify Requirements) = Disposal Field {Specify Requirements) -------------- �� ) -- ----------------------------- ------- 5 w _ ___-_ }_ {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 certifi s the allowing: "I certify that in the perfor a of the work for'wl&h this permit is issued, I shall not employ any person in such manner as to beta subject Cpmpensation laws of California." ---------------------------- Signed F; ___ Owner ,i - ------- Title -------------------- -- ------------------- - - -- ----------- (If other than owner) FOR DEPARTMENT USE ONLY r ------ DATE __. P1 7 i VX---------------- APPLICATION ACCEPTED BY -• R --DATE -------------------------------------------- --------------------------'•;----- BUILDING PERMIT ISSUED -T ---- ------------- ADDITIONALCOMMENTS ------------------------------------------------------ ----•--------- --- ----- � -+- " ----- - ------ --------- r ------------------------------ -- --------- -•------ ---------------- - ,-9 W_ _ -----.Date ----��a--�-_ - ------- ----- Final Inspection y: --------- SAN - SAN JOAQUIN LOCAL HEALTH DISTRICT C u 0 1_'AA Rav -SM �d'