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- FOR-OFFICE`USE:- .. _ �,- _ - ' ��. • ----- ------------------ _- -_._----- -- APPLICATION FOR SANITATION�PEItMfTT�`'�� _Perm_it No:,_-__��T�_-.- ( ( p p catel � ' Date Issued ---i?__J_P -------------------'-------------------------------------- This Permit Expires 1 Year From Date Issued k Application is hereby made to theSonJoaquin Local Health District.jr a permit to (construct and install the work herein described. This application is made in compliance with County Ordinance No. 5.49 a'nd existing Rules and Regulations: r JOB ADDRESS/LOCATION ._.--r1 5 -- 13 r.------------ -------------------CENSUS TRACT �`_,671--------- Owner's , _71--.------ Owner's Name ----- '�__x + 9�-�_1 L --n--------------------------- --------- --------------- -------------------Phone Address 1._!'Y.G ` i/G[v -- `-------------------------- City l fY- ,r------------------------------------------------•--- V ° `1 � ----------------- Contractor's Name .------ -/e--------- = ------ --------- ------------------License # ----�-- ----------------- Phone ------------------- .......... Installation will serve: Residence ❑ Apartment House❑ Comme ci I :❑Trailer Court ❑ Motel [6tther �► le__ -- _ Number of living units:--- Number of bedrooms_ _-----Garbage'Grinder ------------ Lot Size sQX: _________________ Water Supply: Public System and name _____________________._ ____-_—_- �_ Private [ - z ( Character of soil to a depth of 3 feet: Sand' Silt❑ 'CIO y ❑ Peat❑ Sandy Loam {] Clay Loom,E] 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.) NEW INSTALLATION: (No septic tank or seepaae pit permitted if public sewer is available within 200 feet] aQ PACKAGE TREATMENT SEPTIC TANK Size_________________________ _____ Liquid Depth ____ Capacity J2W--------- Type4� ce /------ Material [r�+P �--- No. Compartments ---;;?-=------------- Distance to nearest: Well __._ _______`_________________Foundation ._�-Prop. Line __________...:..._..._ LEACHING LINE [-r-"No. of Lines __"�--------- -------- Length of each line-----742! ' --------- Tofal`'Lengthe. -'" 'D' Box 4LType Filter Materia __Depth Filter-Material ----------1 .----------------------- -� . -� Distance to nearest: Well __- ___�-______ Foundation __.__-_____ __________ Property Line ---�5-_____________,__ SEEPAGE PIT [ ] Depth ----- ______________ Diameter ---------------- Number _________________-_ -------- Rock Filled Yes ❑ No 0 Water Table Depth -------------- ----- ._ -.-------Rock Size --------------__ i Distance to nearest: Well ----------------------------------------Foundation -_----------- ------ Prop. Line ..-------------------- Ir REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _______________-__--______________) kSeptic Tank (Specify Requirements) ---------------------------------------------------------------------------------- ------------------------___--------------------------- DisposalField (Specify Requirements) ----------------------------•----- ---------------------------------------------------------------------------------- --------------- ------------------------ ----------------------- - -------_, - - --- --------------------------------------------------------------------------------------------------------- ---------------------------------------- f :(D`raw existing and required addition on reverse side) I hereby ceriffy-''that I have re--ared 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-thot in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to -, P lifornia.'� _- ---- Signed �e subpec-t to rkmm ensation laws of Ca Owner ' 1 BY. =------ ----=------------ -------------------------•--------- --------- Titl e ------- (If;oth'er than owner) i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE --- -------------- BUILDINGPERMIT ISSUED ------------`------------------------------------------------- -----------------------------------------DATE _----------------------------------------- ADDITiONAL COMMENTS -------------------------------------------------- - ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- i --------- _ r - - ------------------------------------------- ----- - -- -- -------------------------- -- - - Final ins ection b / P Y ------------- - I------------ - - ----------------.Date --- SAN -SAN JOAQUIN LOCAL HEALTH DISTRICT , E. H. 9 1-'6$ Rev. 5M r