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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT � r •_3 Permit No. -bf,5�. ' (Complete In Triplicate) - ................-- - . f Date Issued .7:n . ........:...... ............ This Permit Expires 1 Year From Date Issued ' r . Application is herebyrmade to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in com'pliaJnce with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATlO .- -3 -... " ......--f L- - L- - .-.._.......... ..... - .-........CENSUS TRACT ... �r ------ - Owner's Name�-tS %{SltP1�. - --- ----- - ----- - .............._.. - Phone tt�� Address .-._ - o_L�.. rl . 1 - ------ ------•-- City ...... - -------------------------------------------- �ine --- - _.. . -.. .. .a:- ----------------------.�='License ----------- Installation will serve: Residence partment House C] Commercial(]Trailer Court 0 1 i Motel ❑Other ------------------------ Number of living nits:-.-_J-_- Number of bedrooms -_-ma---.Garbage Grinder ------------ Lot Size .... rte" ��- Water Supply; Public System and name -------------------------- .............................- . ---.......................... . ..Private Character off tL a depth of 3 feet: Sand 0 Silt]] Clay [] peat❑ Sandy Loam {] Clay Loam.[� f • Hardpan E] Adobe L] Fill Material ............ If yes,type ....._.................. .. i (Plot 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 permif#ed if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANKT ] SiZ.e------------------------------------------ Liquid Depth ------------------------ r Capacity .. Type, -----------1 Material..--- --------------- No. Compartments ..... .....:.....:.... fDistance to nearest:. Well ................f.. -. --..........Foundation ...................... Prop. Line ..-._-.---_......... LEACHING'LINE [ ) No. of Lines ...................... Length of each line--------------------- _- _- Total Length ..... .......... ' 'D' Box ... Type Filter Material ............. . ....Depth Filter Material -.----- ...... .... lDistance to nearest: Well ........--- ----------. Foundation ------------------------ Property Line . ....... SEEPAGE,PIT' [ ] Depth .--- -------- .... Diameter ---__--_----- Number ---------------------------- Rock Filled Yes j] No C3 I � Water Table Depth - - ----------------- - -• --Rock Size .............................-------- CO I Distance to nearest: Well .............................. ......Foundation .................... Prop. Line --------------- REPAIR/ADDITION(Prev. Sanitation Permit# ........._..— -.------___-._,_Dati -7!7::"-.T.'..............) � Septic Tank (Sp,cify Requi�,ements) ---------- --.' .. .1. " -_- _ - .... -................................ Dispdsah Field (Specify R quirements( .-- . .-._ w -- l-....i �.Ds2... - • -,G c - -- --n--------------- - - ---------L ..............,....... ----•----------- _ ...... (_ .-(Drdw existing and required 'addition on reverse side( I hereby certify tkat-I-hve piepctred ihil application and that the work will be done in accordance with San Joaquin Count' _Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "Icerty'fy that in the performance ref-the work for which this permit is issued, I shall not employ any person In such manner as to Wetome subject to Workman's Compensation laws of California." 1 Signed ` - - 4L� ------------ Owner By ----- - !- - - - -: Title - - -.._...-.. . --- - - - ....................................... - rrI (if other than owner) f FOR DEPARTENT USE ONLY - APPLICATION ACCEPTED B = - - -i ° DATE _. --------.... BUILDING PERMIT ISSUED ................. -------DATE __------ .................._........ ADDITIONAL COMMENTS .. ................................... ......._.........--......- .......................................... --------------------- - - - - Final Ins edion b ........... ...... ...........--------- - ------ ---- - --------.. ......---- G, PY: - -- r` - - - ---------• - --....-- - --------------------------------------------------Date _.- ------- ----- - ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT