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max— .,FOR r1FFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. 7-�-------------- (Complete in Triplicate) Date issued -_ - --------- This Permit Expires 1 Year From Date Issued A lication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein PP described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: _� .,�,.-_- ,.,: ... CENSUS TRACT. - " --------- -- JOB 'ADDRESS/LOCATION ._------ l dam' Ph i one Owner's Name . City r t - Address '----`---- -- --- atY; � J k- ------------- J ---License #0g6 Phone Contractor's Name } Installation will serve: Residence lApartment House,F-1Commercial ❑Trailer Court ❑ Motel F�other bedrooms G .. arbage Grinder .___'�"�-- Lot Size -.--�----------------- .............. Number of living units:.-- �__.-- Number of Private �( Water Supply: Public System and name --------------------------------------- Clay Loom 'El to a depth of 3 feet: Sand❑ 5_ilt.,[] Clay ❑ Peat❑ Sandy Loam ❑ Y' ❑ ;.. ! e -------- ---------------- - Hardpan,0,, : Adobe [J Fill Material -___.- -._-- if yes,type buildings, etc. must be placed on reverse side.] (Plot ,plan, showing size of lot, location of system in relation 5•to weals, ff NEW INSTALLATION: (No septic1tank or_seepage pit permitted..if.-public se'"wer is available within 240 feet) 'SEPTIC TANK 1 I Size ------------ Liquid .Depth -------------------------- PACKAGE TREATMENT [ ] �-- 1 Material---------------------- No. Compartments ------------------•--- f' Capacit 7Ype ------------- - Fes, Y - - �. Distance to nearest"1NelE Yti= ------`--------Fo yndation ---------------------- Prop. Line ------------=----•---- e`ac -------------------------- { s , i' --- --- Total Length __ LEACHING LINE [ ] No. of Lines ---------------- ----------------- Length of each line.----.------.---- g De Depth Filter Material --_------- i � Filter Material -------•---------------�..----•- P Distance to nearest;�Wel)�--•—----_n- === --- Property Line ------------------------ Distance -- - - D' Box ---- ------- Type e-rrrt• f % u 3 Rock Filled Yes No p;T` Depth Diameter -- � l �imber DepJ/ ---� --- ---------Rock Size ------ ------- �'Up'1 Water Table Depth ------------------7- .�� Z -------- Prop. Line ----•- i l Distance to nearest: Well _-----_--J---_--_---f_-_----------Foundafiion _- -. �-- Date -`-'-:-`---------•-------•'---------) REPAIR/ADDITION(Prev. Sanitation Permit -------------- 1 -= - Septic Tank (Specify Requirements) ---- _------- ------------------------------ t Disposal Field (Specify Requirements) ------------- ---------------------------- ` ---------`---------- I ,9 -------------------- ----- ----------------- --- ; ], - ---I -------------------------------- ------ • r3--f F --------------- - ------ ----- '-----�-- '- -e t � (Draw existing and required addition, reverse side) i k 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordir}ances, 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 flie performance of the work Eor which this permit' is issued, I shall not employ any person in such manner as to'become subject to Workman's Compenaati.on laws of California." - i I <-, _ Owner Signed ------------ By --- --- --- u � --------------------� Title --- -- -- ' ` (If other than owner) r 1 FOR DEPARTMENT U.SE`ONLY DATE __�74�.q�-•-- -------'-------- APPLICATION ACCEPTED BY -- ---- - ------------- ------------------------- DATE--:-- .__. BUILDING_PERN4IT"ISSUED -----------------------------_ . - ----------- --------------' tom- ADDITIONAL COMMENT ------ ----'- --- ---- - ----------- ------- --------- -- --- u.,--- i�rts4+i^�,�----- - --- - - ---- -- --- ------ - ---- ------ - 1Date . Final Inspection by: -- ------ --- ------- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT CG T - F u 0 1-'6B Rev. 5M -