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1 C R OFF:b USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit ho. _TL7-f_P-y_P ----------- --------------- I This Permit Expires 1 Year From Date Issued Date Issued ;el Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION ._ �' �� fP - - ------------------ - --------- -- -- CENSUS --- TRACT -------------- Owner's - -----------Owner's Name -- Address -- -- �Q- a-� f- -frl, �----------- ----- City - f ter— c� ,�•- f Contractor's Name - �. " � 1 ��v ' ---------------------- License Installation will serve: Reside n ceXApartmen t House❑ Commercial ❑Trailer Court !,❑ Motel ❑Other i Number of living units:_ Number of bedrooms _ r ,�/ g ---' --- age Grinder// --- Lot Size%Or�� ----------------- Water Supply: Public System and name _, --------- ---------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand''❑ Silt❑ Clay ❑ Peat-E] Sandy Loam ❑ Clay Loam 4 Hardpan ❑— Adobe Fill Material -------- --- If yes, type ---------------------------- V (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 if public sewer is available within 200 feet,) PACKAGE TREATMENT F f r [ ] SEPTIC TANK' Size__- � _ �� ,per.-- -.- Liquid Depth I----------•-------- Capacity _ -- Type/ - Material _ { -r__ No. Compartments _ ___ -------=---- Distance to nearest: Wel! '�"—"� le ' -------------- ------------------Foundation = - ,� --------- Prop. Line �✓�.-=-------- LEACHING LINE No. of Lines ____ -------- Length of each - line - ------ ------ Total -Length --`-- ----------- DBox -- Type Filter Material, Depth Filter Material` --------------------•-----_ -_---- Distance to nearest: Well -------------- Foundation Line ---r- --------- SEEPAGE PIT Depth--1�•— ------ Diameter _`dm _________ _____ Rock Filled Yes NbI No .i❑ y�jC<$T6E Water Table Depth -- Al -- Size/------ --------- 0 Distance to nearest: Well -----:_-_______- --------------Foundation —------- Prop. Line .A. ............ REPAIR/ADDITION{Prey. Sanitation Permit# -------------------------------------------- Date ----------------- ----------------- Septic _____-_--_____-_____ -_---------Septic Tank (Specify Requirements) -------------- - Dis osal Feld (Specify _Requirements) ---/dP _,e -� = 14A !-= ------------- -------- --- -- - - - (Draw existing and required addition on reverse----sid--e--)----------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person. in such manner as to become subject to Workman's Compensation laws of California." Signed Owner ----- --- -- BY - Title - 7t ---- ---- a4eo---•--------- her than owner) -------------- - F R RTMENT USE ONLY - APPLICATION ACCEPTED BY --_-_-- --- -- - ----------------- --- DATE --��---------------- - ------ - ---------- ------------------------------- BUILDING PERMIT ISSUED -_ -- - --------DATE ---------------------------- -- --- ------ - --------- - - ITIONAL COMMENTS ------- __ - ------------------------------- - tib_ _ __ - -- ---------- -------- - !6 S ' - '----�'- F ---------- -- ------------ --------- ----------------------------- -- ---- ----- -- '` Final Inspection b ! -- ---- p Y --- ------------ - --------------- ------------ --------- ------------.Date ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 w 1-'6$ Rev. 5M