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FOR OFFICE USE: _ ------_ APPLICATION FOR SANITATION PERMIT 1�Q:1� FOR OFFICE USE: - ----- ---- - _-_--..---_- ----___-- (Complete in Triplicate) Permit No,,7 ........... -- -------------- This Permit Expires 1 Year From Date Issued Date Issued./,:�,I._lc r 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 Owner's Name -/_7 {LA__CENSUS TRACT------------------- - Address- - T - _ - 7r i Phone_-} _ ZIF.Contractor's Name ' City aL— ------- Installation will serve: ----License Phone. ` Residence p ❑ A ailment House ----------------- Motel -- - ` Motel ❑ Commercial D Tran er Court�] ❑ Other f- ✓ �'- Y_'- 1 � Number of living units: ------- --------------- of bedrooms------------ Grinder' Water Size-.---- Water Supply: Public System and name-_ -Z---- ` -- ----- `Character of soil to a depth of 3 feet: Sand - - - ---------Private ' - ---------------------- - ❑ Silt❑ Clay❑ Peat p Sandy Loam ❑ ClayLoam Hardpan ❑ Adobe(] Fill Material_-------_-If es, ❑` k.. P of plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side,( NEW INSTALLATION:INSTAL: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ J SEPTIC TANK [ ] �. Size ----------- Capacity,/,,_"6'./_, �- ,A ¢ / ------------. -- _Liquid Depth. - -- ---- } Ype f.' s:r =.lvlatenal r-re r r_!I�o. Compartments--- Distance to nearest: Well-_-__ ,•,j-- i � s - - r LEACHING LINE r ------------Foundation---�_'-Lam -----------Prop. Line.�;�:- ccf4 ,J [ ] No. of Lines / ---_ ----.Length of each line_ Total Length -----_ 'D' Box----�--_--Type Filter Material<<_-: -___,�...-tDepth Filter Material.-------__,' 9 -=--- ----------------------- Distancetonearest: Well '/ --- -- l r PIT — Foundation------ -SEEPAGE -----------Property Line- Diameter] Depth �=----Diameter ,�.- r,, , - -�. ---�� Number_ .. Rock Filled Yes ❑ No ❑ Water Table Depth----------- ----------------- Rock Size-- / " '__ Distance to nearest: Well-_.G ` '` -. Foundation __ �, -------- -------------- REPAIR/ADDITION (Prev. Sanitatij Permit#--_-.--- Prop, Line------.--_---__-_-:-- �— _;,. --------- ----------.Date----------------------- .................. eptic Tank (Specify RequiremenTsj' � ) -- --------------------- posal Field (Specify Requirements)- -- ------------ - ----------- ------------------------- - -- ---------�------------------�-- ----------------------.-_--- �--- ------- - --------- ir;'----------------------------------------------------- - - -----------(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 rdinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents ftnature 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 become subject to Workman's Compensation laws of California." rigned----- --- - .. •Y, _______ �.y /. ._-.-- li 1. y - - - -- -Owner ---- / -� c r %•�/ 1 ----- Title--------- � (If other than owner) - -r'-- ----- -- ------ - --- ------------ OR EPART NT USE ONLY 'PLICATION ACCEPTED BY-_------- - - - - S fyVISION OF LAND NUMBER.- - - - - - DATE -o 1 -- -ADDITIONAL COMMENTS -� - - - ---- --------------- -------------- -------- ----- -- - -" --- -- - - - --- -------------------- -------- ------------ ----- r--------------------------------------------------------------------------------- - - - - - ---------------------------------.--_ `--- -----a------`----- -inal Inspection b -------------- -------------- ---- ------------- ---------- --------- ate --------------------------------------------- - - - - SAN JOAQUIN LOCAL HEALTH DISTRICT • ( roa�677 REV. 7176 9M '