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FOR OFFICE 115E: APPLICATION FOR SANITATION PERMIT � -------• ------------ Permit No. --1-7 (Complete in Triplicate} - - - ------- ---------------------------------------------..�,.� � � Date Issued -------_------------------------_--______-_----------_ , This Permit Expires 1 Year From Date Issued - 3 330 -0 Application is hereby mode to the Son.Joaquin Local Health District for a permit to construct and install tZe work herein described. This applicationlis'made in compliance with County Ordinance No. 549 and existing Rul nd Regulations: t� .--CENSUS TRACT ------------------ - JOB ADDRESS/LOC T N ---- -------- -IN Owner's Name -------------------------------------- --- ------ Phone Address -- fes =---------------- ----------------------- City ----------------------------------•-- .�C��),,,�-�,�� Contractor's Name ----- `- -----------------..License # �51��3 Phone Installation will serve. Residence ❑Apartment House❑ Commercial❑Trailer Court ❑ Number of living units------------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size 4 '_..t Water Supply: Public System and name --- -----------------------------------------------------------------------------------------------------•-----Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ElPeat❑ Sandy Loam Clay Loam E] # Hardpan ❑ Adobe ❑ 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 permitted ifgublic sewer is available within 200 feet,) � PACKAGE TREATMENT { ] SEPTIC TAN Size_Iy__�°� - --------------------- Liquid Depth _s-------------------- No. Compartments ----t -------- -._� Capacity 1.9-o ____.--- Typ� -- Material_---- - -- - k Distance to nearest: Well /�_ -----------________________Foundation --------- Prop. Line Q LEACHING LINE �! No' of Lines -------�-------- Length of e line----%54_4 -'4-' Tata) Length 0�_ _U-___.______ -� 'D'6 Box ----�_---- Type Filter Material St __ _Q�epth Filter `Material -- _______________________________ _ pistance to nearest: WeII Ace__---�_____ Foundation �d Q --------- Property Line. _15--_ - 4 Rock Filled Yes No ❑ SEEPAGE PIT , [ ] Depth -----------4__------ Dlarr-eter> ---'�----_--__ Number -_- -- ---�----------- ❑ �+ } Water Table Depth ------- --------------------------- --------Rock Size -------------------------------- _ ~0.? ____________________________________Foundation - _____ ._________- Prop. Line ___.____.-_-_-_-__ Distance to nearest: Well _. - REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------------------- Date ----------------------------------) r l SepticTank {Specify Requirements) --------_--------- ------------------------------------------------------------- -----------------..----------------------_--- ° u 3 Disposal Field (Specify Requirements) ---•--------------------- --------------------=---------------------------------------------- --------------------------- ----------- t 3 � --------- ---------------------------------------------------------- ----------------------------------------------------- (Draw existing &nd 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! State1aws, and Rules and Regulations'aUthe`San Joaquin Local,Health District. Home owner or licen- sed agents signature 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 to bec e bject to Work an's Compe ation laws of California." I Signed ---- tol� Owner �. a -- - --------------------------- Title -------- ---------- --------------.------------ ------------------ (If other than owner] FOR DEPARTMENT°USE ONLY : I APPLICATION ACCEPTED BYE -� � �.t�.--- --------------------------- DATE i --------------------------------.- BUILDING PERMIT ISSUED "�- ... ------------ ------------`----�-----------------;--------- DATE - -- ------------- ADDITIONALCOMMENTS ---------------------------------------r---4------------------- ' --------------- ------------------- ------------------------------------------------ -- -----------------------------------------------------------------------------------------------------------=-----------------------------------------------------•-------------------------M- -/, -------- r ` j ------- .. E r� Date --------------------------------------------------------------------------- --- !�� Final Inspection by: - - '-- - - - - -- - - ---------------------- ---------------• -------------------------- -- ---- f -- SAN JOAQUIN LOCAL HEALTH DISTRICT 1_'AA Ravi SM