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r � i FOR OFFICE USE: t. APPLICATION fOR SANITATION,.,a�PERMIT'' �, � ', �) ��i { s . .- h -* x. Perm Et No ---- ----- ---------- �.. 'Complete in Triplicatel-�--•--.�...�-:.�.-... •.-- � ---- ---------- -----------'-� _ x Date Issued _-�,V;7..z- ' This Permit Expires l 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 App ibed. This ereb bpplcation is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: I ] - .-�0� 7-°Lr_1Q,``� �I�c -r- --------------------CENSUS TRACT ----------------s--- JOB`AbDRESS/LOCATION;.:____��-� - -- Phone Owner's Name - � � r - -------- -- -- Address °�'�cX�- --------- City T r r7 '��---,---------------- -- 7 x -____License # __ � 1_._ Phone _/ .�o -�lQ=7 Contractor's Name _ .�.-�- ' , „ y Installation,wiliserve: ! Residence 4Apartment_House.❑_Commercial:❑Trailer Court. :E1 f Motel ❑ Other ------------------------------------------- Number of living units. Number Number of bedrooms ____'�2Garbage Grinder __-- -- Lot Size ____. ' Private (�[ Water Supply: Public System and name ------------- -------------------- - ------------------------- `---------------------------------- Character of soil to a depth of 3 feet: Sand' Silt❑ Clay E] Peat❑ Sandy Loarr Clay Loam ❑ I` Hardpan ❑ Adobe E] Fill Material ` ------ if yes,type ---------------------------- y 1 j (Plot; plan, showing size of lot, location of system in relation to wells, buildings, .etc, must be placed on reverse side.) ` . k NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is avaitable;within 200 feet,) F [ ] Size-----------------------------------•- ----. Liquid Depth ----------------•----.----- SEPTIC TANK [PACKAGE TREATMENT Type ____ -�MateriaiF"� No: Compartments Capacity ------------- - s� -- - yp k '._Foundation Prop. Line -- 4 _ Distance to nearest: Well ____________ _ a LEACHING LINE �j(J No. of Lines -------I______----- Length of each''�line________�49 ------ Total Length __ ----•..--------• Box =~= T ----------------- Filter-' Material ----- ype Materia! ______ -_ __.D'epfih EIlter, ' € ' '� — -- Property Line -__� ---------- IDistance to nearest: Well l� ------------ Foundationl* -- _ . ' SEEPAGE PIT [ ] .Depth _ Diameter ---------------- Number --� --- ----------- Rock Filled Yes ❑ No.`s ------------------- Water Table Depth _ Rock Size--------------------------------- ----- --- -------- ------------- ----- .. w ;Distance to nearest: Weil --Foundation --------------- Prop. Line -------_------ I REPAIR/ADDITION(Prev: Sanitation Permit# ------------------------------------------' ---------- ------) --=ti-- -------- - ----------'j ' a 41 ' Septic Tank (Specify Requirements)1.__"t.-_-4-:-- ""- - _ "' _ ---------------------------- ------------------------------ -- - ------------------------ - Disposal Field (Specify Requirements) '_-_------------ V - - -- ��' 3' ------_--------- ------------------- -------------------- - % - } ----'------------------------------------------------------------"---'------------------------,-.--------;r-----`--- --------------------------- (Draw existing and required addition on reverse'side) ( � F application and that the work will be done in accordance with San Joaquin' ' l hereby certify that I have prepared this app County Ordinances, State Laws, and Mules and Regulations of the 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 shalt not employ aetiy person in such manner as to become subject to Workman's Compensation laws of California." Sign ---------------------- _ Owner ` ---------------------------- ---- -------- a Title i B ., .. y . • (if other than owner] _ FORDEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- # t _ ------ ----- DATE -----7- 4------�=�-------•---- BUILDING PERMIT ISSUED - - # - -DATE - ADDITIONAL COMMENTS ------------------- t,. i ___________________________ C ____________________________________________________________ ______________ ,_ _____ _---__ _____________________________________�4� ' _______---_________________.___________________________-______-______________________ _ _. ------------------------------------------------------------------------------------------------ Finalans-.Inspection b ---------- Date --------------------------- P Y- ---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT r u o 1_'AA Rav 5M