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FOR OFFICE USE: l APPLICATION FOR SANITATION PERMIT Permit No, --7- =-�' 5 - ----- ------ - --------"------------------ (Complete in Triplicate or -------------------- - ------------ ---------- Date Issued This Permit Expires 1 Year From Date issue Application is hereby made to the San Joaquin Local Health District fora .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. CENSUS TRACT ---. --- -------- JOB ADDRESS/LOCATI N Q----------/L - — ---------- ------Phone ------------------------------------ - Owner's Name -------- OR-6-at _------ - � Address ---- -l0 5 ---- ---5------- Contractor's Name -------O --------------------------------------License # -------- -- Phone ---- -----------------•------- Installation will serve: Residence partment House❑ Commercial ❑Trailer Court Motel ❑Other -------------------------------------------- Number of living units-----I----- Number of bedrooms -- Garbage Grinder/ Lot Size _- - •, ----------- -Private Water Supply: Public System and name ----------------------- --- Cl Loam Character of soil to a depth of 3 feet: Sand'❑ Si ❑ Clay ill Material �p---❑ Pe.at Sandy Loam (] Y' � if Yes,tYPa -------------------------}-lardpan � Adobe-[I (Plot plan, showing size of lot, location of system in .relation to wells, buildings, etc. must be placed on reverse side.) � NEW INSTALLATION: iNo septic tSize--------------------------------------tank or seepage pit permitted if public sewer is available within 200 feet,} { ] SEPTIC TANK'[ ] --- --- Liquid Depth .---------- PACKAGE TREATMENT *! Capacity `' T y e ------ Material--------------------- -No. Compartments N 1 Distance to nearest: W l ----- - - ------------------------_Foundation --- ------------------ Prop. Line ---------- LEACHING LINE [ } No. of Lines --------------- --i----- Length of each line---------------------- ---- Total Length V1 -Depth Filter oteriaE ------------------------------------- -- `D' Box ---�-------- Type Fil er Material ------------------- ----------------------- Distance to nearest: Wel ------------- Foundation Property Line -"- ------------- Number --------- -------- -------- Rock Filled Yes ❑ IVo IC�f SEEPAGE PIT [ ] Dept �i - � --t----- Di eter Rock Size ----- , _ ' i Water Table-Depth ------ ------ -----f•-=-�.L=.---------------- - ..�. -�-.�....�. ,�,.... c ---_: -- ^--_, ` Line .. - Foundation - Prop. Distance;to neares#: W -�- ��i{�r f. Date I---------- ---- REPAIR/ADDITION(Prev. Sanitation Permit# ---- !� Septic Tank (Specify Requirements) ----- ----- ------------ - ----- --- --- ------------------ Y--- ------- Disposal Field (Specify Requirements] -----0.©y -,------- �� t. -1,144-1�.�.-------------------------------- C ----------------------------------- F-F-M-£�-------N-17---- ----- 9----- -- l - - ------ "'---- (Draw existing and required addition on reverse side) certify that I have prepared this application and-,that .the work willbe done in accordance with San Joaquin I herebyr . County.:Ordinances, State laws, and Rules and Regulatians.off the San Joaquin�Loca�l ,Health D`itstrict. HQ owner or licen- sed agents signature certifies the following: ' permit is issued, I shall not employ any person in such manner "I certify t in the perform nce of t e ork for which this p as to bec a subject to mast's C p sa io laws of California." -' -__:-_- caner ..,,.. i ----- - Signed '� ----------- i '-_ -- .�� Title ------I ---- ------- ------- ------- --- ---- --- ----------- (if other than owner) - - --- FOR .DEPARTMENT USE ONLY ��. DATE 7 APPLICATION ACCEPTED BY --__ -�K-`--------- - ------------ ---- = --------- ---------------DATE ----------------------------------------- BUILDING PERMIT ISSUED ------------------ ----- --- --- - ADDITIONAL COMMENTS.� - --------------------------- ------------------------- ----------- -- ' ._... := . ------------------- - ---- ----- - _" if- . �Date --------- ---------------------------------- - ---- ----- _ - --------------- Final --------- Finallnspe on SAN JOAQUIN LOCAL HEALTH DISTRICT r . ! E. H. 9 1268 Rev. 5M