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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ 0 3 Permit No: .��-•/---------�- - ----- --- -- ---------- ----I (Complete in Triplicate) - --- ------------------ Date Issued ----- - - This Permit Expires 1 Year From ate issued _ _ �-- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein PP lication is made in compliance,Lith-County Ordinance No. 549 and existing Rules and Regulations: described. This app ' ) CENSUS TRACT ---------------- ---•---- JOB ADDRESS/LOCATION .---- l'+• f Phone - ------------------------•-----•-- ---- Owner's Name --------------- - -- ------- 1 --- -- ------- ------ --- ' -- ------~---. City - - -- - - ---- - ----�- --------------- -------------------•--- 'Fa - --------- "L -- - - --- ------- - ---------------- Address -----. - T v- -- -------.License # 10�1�� ------ Phone - --- Contractor's Name -_..------ --•----- Residence Apartment House -1 Commercial:[]Trailer Court ,❑ t installation will serve: f --------------- Motel ❑Other - �� / 6 Garbage Grinder -- ---�---- Lot Size ---------------- N,m�er of lqliving units:.- --------, Number of bedrooms _ -------Private ❑ " ` me -------------------------------------------------- Water --- Public System and name _-------3----- -------------- - Water Supply: peat❑ Sandy loam ❑ Clay Loam ❑ + _...... � Silt[} Clay ❑ Character of soil to a depth of 3 feet: Sand' Hardpan ❑ Adobe Fill Material --------- if y�s, type ------------------- ------- (Plot plan, showing'size_of lot, location of system in relation. to wells, buildings, etc. must be placed on reverse,side.} NEW INSTALLATION: (N6 septic tank or seepage pit permitted if public sewer is available within 200 eet, Sie f: S":"�: _. -- I---------- Liquid Depth ------------ ----•- ` PACKAGE TREATMENT "J"J.�SEPTICTAN K'( I � � 1 � Ca acit - ! Type -----•------------ Material- ------------- - -- No. Compartments -----------• p Y , t Foundation Prop. Line Distance''.to,nearest:I Well - i • _ -Length of each line--------------------�------ Tota en LEACHING LINE [ ] No. of lines*-------------- --------- - --.': '"" _ th Filter' Material ------- -------------------- Y--'D' -- ,.Y•-k D' Box i.__-_---*'- Type, Filter Material -� �- P �..,:-_-,._.._........ .... , Property Line. ------------•--•----••-- Distanc-16-nearest:_W�]I_--;_ = ? '"Folin ation ------------------------ Property �) �____ Rock Filled Yes ❑ No )❑ De th Diameter ---='- Number ------------------- SEEPAGE PIT 4 I 1 t P ., " , `. ` --- ------ -_—� - __Rock-Size - -- - -- ------• I . i Water Table Depth. °"_ _ Prop. Line ---------------- - f- Distance to nearest:rWell --------------- -4_ Found`ation --------- --- p ---- Ddte _-! REPAIR/ADDITION(Prey:Sanitatio Permit'# -------• = 4.r� N-> ------------------------------------•'---------------------------- • Septic Tank (Specify Requirements) ___ __ w _..__ ---- ------ --- - P Y y = -_---------- P Dis osal Field (Specify Requirements) ,��'`� ------ ------- ---------------------- -:.- �.m ------ -------t------`------- ---=-- -----red addition `='T ------------------------------------------------ -- --- --------- (Draw existing and requi on reverse side} -- _e t h SO 1 hereby certify that I have prepared this application tof the San Joaquin Localuin oHealth D str'iie in dCanHome ce 'tawner or lcen- County Ordinances, State Laws, and Rules and Regulations ` sed agents signature certifies the following: t ;. i arson in such manner "I certify that in the performance of the work for whichihis#perrr+it-is issued, I shall not employ any p as to become subject to Workman's Compensation laws of California." { ; . Owner --------------------- -- - Signed = ----------------------- -- ---- -- - - =- Title (If of than owner � . FOR .DEPAitTMENT USE ONLY ` DATE !_/_may 7 -------------- : - ,�;� , APPLICATION ACCEPTED BY ------------------------ - - -------- --------•-------••-------- •------------- ------- --- -� - --- - - DATE :------ ------- BUILDING PERMIT ISSUED = ADDITIONAL COMMENTS __lx-- ----- --7(____---- - ._' _, .--- ----- � ------- -------------------------------- ------------------------- --- ----- -- -------------- ------------------------------------ -- -- --- - Date ----./ - ---'a -'7--------------- Fi ------------ --- ---•-- / Final Inspection by: -------- �------------------------------------------------------ --------- - SAN JOAQUIN LO- -------- - CAL HEALTH D1STR1C7 G u 0 1268 Rev. 5M