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OFo� IC^E usE: r APPLICATION FOR SANITATION PERMIT q ------------ -------------------- . Permit.No: - _ ---j -� - -�� °�_ -� � [Complete in Triplicate) � ' ------I----------- ----------- ----- Date Issued ------------------- ---------------------- - This Permit Expires 1 Year From Date Issued f � , s 1. Application is hereby made to the San Joaquin Local Health District for a permit to construct and ns 1I`the k- erein described. Thi4_0 licati i�..4nade in compliance with County Ordinance Na. 549 and existing Rues and, Reg io s: JOB `ADDRESS/LOCATIO - : �(�------------- - ----CENSUS TRACT -` Owner's Name 4I _�__ __Phone - __-- -. - r� Y61- ? Address > 0N = City 0 i---------------- Contractor's Names License # - Phone _ _ F Installation will serve: Resi nce �artment House�❑ Commercial ❑Trailer Court ❑ xl _.. .._.. .__.._.._ Motel ❑ Other.. ..- ---- i Number of living units:---1.------ Number of bedrooms -3------Garbage Grinder Lot Size _/gC og-ap- PP.Y Public System and name - ----••------ Water Su f ~________Private Character offsoil to a depth of 3 feet: Sand'❑ Sil Clay ❑ Peat ❑ Sandy Loam -❑ Clay Loam 'er i ~ Hardpan Zr Adobe ❑ Fill MaterialIf yes,type�- a -;: ---------- (� � _ --- (Plotplan, showing size of lot, location of system in relation to wells, buildings, etc. must be�placed on reverse side.) N NEW INSTALLATION: (No septic tank or see a pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ } SEPTIC TANK'[ Size------------------------------------- ---- Liquid Depth ---------------------.-•-- ............ �N i -- T - } Capacity ----------------- Type -------------------- Material----------------------- No. Compartments --------- 9 Distance to nearest: Well ------------------------------------Foundation .... ----------------- Prop. Line -----•----................. 0� LEACHING -- `� ------ Total Length /S a, U LINE [Ir No. of Lines -_____ ____- g g Y' D' Box _ P -_-______._ Length of each line____.__ Type Filter Material - Z._De th Filter Material ------I--1------------------------------ Distance to nearest: Well___ -_ Foundation Property Line .-,------" ....... __ _ Rock Filled Yes' No 0 AGE PIT ] Depth -- - .......... Diameter-�-I- --- Number ------ ----------- a------ � SEEP} a ---_--Rock Size = ------ Water Table Depths �'-�-"L._ 1 I I l Distance to nearest: Well ----le)o------------------------Foundation .�0--'" _- Prop. Line ___ .. ' i REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ___--_--_----_--------------------] Septic Tank (Specify Requirements) -------- ---------------------------------------- --------------------------------------------------------------,..------------------t-------- - f Disposal Field (Specify Requirements) --------------------------------------------------- ----------------------------------------------------;--------------------=-------- s -------=------------------- ---------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) ` 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 I!cen- sed agents signature certifies the following- "I ollowing:"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 TitleLL-------- ------------ ---------------- s (I other tha ned FOR DEPARTMENT USE ONLY �^ APPLICATION ACCEPTED BY --------7771&__-'O------------------------------------------------------------------------ DATE ....... •Z "` '' BUILDING PERMIT ISSUED ------ ------- -------------------- -------DATE -------------------------------------- ADDITIONAL --- --------•-------------------- - ---------------- ADDITIONALCOMMENTS ------------ - ----------------------------------------- •-------------------------------------------------------------------------------------------: -------------------------------------- -- -------------------- --------------------- - ' ---- ---- ---------------------------------- --------- ---- ----- - - ------------------ ------- - -- ----------------- . D Final Inspection -------- --------- --- ate ---- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 1 F H 9 1-'AS Rev- 5M '