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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT permit No !--�`� 5 -- . --- (Complete in Triplicate) Date issued . - — p - ----------------------- ----------------- - -------- This Permit Expires 1 Year From Date issued -------------------------------- --- i with County Ordinance No. 549 and existing Rules and Regulations: Application is hereby made to the San Joaqu�ian ec wHealth District for a permit to construct-and install the war erem pp S ` I described. This application is made'in camp ! -CENSUS TRACT ------- - --------- ----- -d-� ----- ._F_Phone ---------------------•-------------- J013 AlDRESS/LOCAT ON .--- -TMJ - F= Owner's Name City . ------------------------------------- .- - ---- ------- -------------- -- - Address ----- --- - ------- `� ��- -- - Phone ------ -- ------ � -- --------- - _ _ License # -�1�. - contractor's Name ------ .--- Residen� Apartment Hou a�❑ Commercial ❑Trailer Court �,❑ i F Installation will serve: a -Motel ❑Other _. ,"--- --- - - - - - ----------_---- _ _ _ Lot Size - ----- ---- ----- ------ i Garbage Grinder ""_'�-- - , - Number of living units: "" -- Number of bedrooms -- private [�� --------- ------- -- ----- j Water Supply: Public System and name ------------ = --------- '"'" Peat❑ Sandy Loam ❑ Clay Loam ❑ Character of soil to a depth`4of 3 feet: Sand'P/Silt❑ Clay F-1 i Hardpan ❑ Adobe [:j Fill Material :--�-- If yes,type -----------Z- L'^ laced on reverse side.t' � (Plot plan, showing size J. lot, location of system in relation to wells, buildings, .etc. must e p public.sewer is available within 200 feet,} J NEW INSTALLATION: (No septic tank or seepage pit permitted I p ff X �._ J ,�/ Size---- x--�. ---- -"- Liquid Depth ----�----•-------- E SEPTIC TANK'[`T` PACKAGE TREATMENT { ] e --- No. Com artments --------`----- i Capacity'- -f� TypeMaterial------ ----- -- Ip S O 1. Foundation -- /V.... ------ Prop. L'+nem --------------- - ~• Distance!to neare Well ------'Sp----� � Total k Length ._ ""lJ..-----.----"-.... .I LEACHING LINE {✓]/ No. of Lines ----- ---- ------------ Length of each .line*ti-"��-- V - , l.�f'"_ a Filter Material "d--I�------Depth Filter Maternal�-.,.�+ ------- -- , E D. Box ------- Type w- —Property Line -- -----:..-- Foundation w �p ty i s. I Distance�to nearest: Well -_-" -- .� .-. x Rock Filled Yes j] No, + Diameter ---- Number ----------- -"--- -- SEEP PIT L Depth fRock Size -------------------------------- l Water Table Depth - ---------- --------------------------- -------- ' ------Foundation -------------------- Prop. Line -------------------- - pistance�to nearest: Well --------------- ---- - ---"--� Date ----------------- --------- r_ REPAIR/ADDITION(Prev. Sanitation Permit# --------------- -------- ------,---------- -------------- 4 Septic Tank (Specify Requirements) ------- ----------------------------- ------------------ ---=-------------------------------------------- Disposal Field (Specify Requirements) ---- ----------- --------------------------- - ----------------=------------------------------------------------------ ------ ------------------------------------------ i ----- ----- ----- ----------"" (Draw existing and required addition on reverse si e l I hereby certify that I have prepared this application and that the work will be done in accordance with San loaqu n County Ordinances, State Laws, and Rules and Regulations of the San Joaquin local Health District. Home owner or �cen- sed agents signature certifies the following: person in such manner "I certify that in the performance of the compensation for which flaws this California."permit is slued, l shall not employ any as to become subject to Workman's - --------- Signed .._ ------------ ----------- ----------- --- - -- -- ----- ----- - -------------- By ----- ----- - - ------------ ------ - Title --- ------ ---- -- - - (If other than owner FOR DEPARTMENT USE ONLY � M - � ----- ----� DATE -- - ---- ----- ----• ----------------- --- -------------------------------------------- -----DATE -------- ---------------------------------- + APPLICATION ACCEPTED BY ""-- ------ - ------------------------------"-- _ BUILDINGPERMIT ISSUED --- --------------------- ---------------------------------------- ----------------------- ------------ ------------------------------------ ADDITIONAL ------------------•-- -- ---- ------- --------------=------------------ --------- ----------------- ------------------ -- l- ADDITIONAL COMMENTS . --- --- --- ---- ----- ------------------------------------------------------------ -- ---- -= ------- ------ -------------- ----- - --- ---- ----- ---- ------ ---------- --- �"_ -- __ --------------- --- ----------- - -- Date _ - ---------------------------- ----------------------------------- ------Final Inspection by: -- - -- •------+ ----- ----- - N SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6B Rev. 5M