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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. .................................. ...---. .�.......... (Complete in TAplicate) ' '' Date Issued .. :... ... This Permit Expires 1 Year From Date issued ........................ . 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: i .............. CENSUS TRACT .......................... JOB ADDRESS/LOCATION .._Ily. �� •- !/Y .t �c -•.•....................• Phone y 4 :.......... Owner's Name RP� ...+�L��Sf'JC� ..................................••-• , I ...... City i _1. 7s� Address ------------- -•---- ..__... f��.--�__...�,�.__L�_. . lid -- ------• ••--•-•-•---• 7............License # a_ Phone .............................. . .. Contractor shame ............ e.-- -•--.--._ a_�.�n_:.._�_.. Installation will serve: Residence OT4partment House] Commercial ❑Trailer Court ❑ Motel ❑Other .............................. ............ k Number of living units:............ Number of bedrooms ...---------Garbage Grinder ------------ Lot Size ....______ ................................. Water Supply: Public System and name ----------------- .......................................--------................. ........................•--....Private ❑ Character of soil to a depth of 3 feet: Sand❑ . Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe.❑ Fill Material ------------ If yes,type ------_---------•-- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.. must be placed on reverse side.) � 4 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) w , PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size: Liquid Depth .......................... ate F Material ----- No. Compartments ...................... LTi 1 [ Capacity . Type ...-----•...----• ---... Distance to nearest: Well ....................................Foundation ......._. ............ Prop. line ..................... - Length of each line..-- ._. j t . LEACHING LINE [ ] No. of Lines ._ g -•-•-------..._`....- Total Length ......*0.............•• � D' Box Type Filter Material __.Depth Filter Material E Property line � Distance to nearest: Well ..................:..... Foundation ...___..___........._.._ p n Number Rock Filled Yes ❑ No ❑ Z Diameter SEEPAGE PIT --------•- ---- j ] Depth . RockSize ...........-•................... Water Table Depth --------------------*-------- Distance to nearest:'Weli ........................................Foundation ..................... Prop. Line ------------- .-.---- Date .:...........................•-••-1 REPAIR/ADDITION(Prev. Sanitation Permit.# ------------------------------------_ , t . ... . . ... Septic Tank (Specify fY Re quirements) ....... ..... . . Disposal Field (Specify Requirements) D ..�c .. f ... , --------------------•• •-------••----...-•-------- •---•.. .............. ..................... ----....---•--•...__..._... ?. ............... ............................. -- r ........................ ...-------•----------•_....- k - - (Draw existing and required addition on reverse side) •,�� I hereby certify that 1 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 A the San Joaquin Local Health District. Home owner or licon-';' / sed agents signature certifies the following: t "I certify that in the performance of the work for which this permit is issued, { shall not employ any person in such manner as to becomes ject to Workrry�n's CompensaL tion Taws of California. ` " Signed Owner ........ Title -------------------------- ......................--------............ ...............................• 4^x•11. I (If other than owner) FOR DEPART NT SE O tY APPLICATION ACCEPTED BY ....................•-•--••-------- -- - --_.... DATE _ :> .................:.... BUILDING PERMIT ISSUED ••••. ---.DATE ........................................... ADDITIONAL COMMENTS ................:..........--•.................----.......----•-•---•-.....-•---•-•----............---- ..............••- i ..-----••--••- .......................................... --- :.:. --••----------•-------------------------- yr ---••--•--- ----• ----•• - -..............•----------------------••-------•------------..__.....-------'Date _. ,/�... 4 Final Inspection by: ...: -- - - ---------------------- SAN AQUIN LOCAL HEALTH DISTRICT III 9A . As 7/723-H