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FOR OFFICE USE: z r.. APPLICATION FOR-SANITATION PERMIT ' --------------------------------------- (Complete in Triplicate} Permit No. ---------- ---------------------------- - -------------- p This Permit Expires 1 Year From Date Issued Date Issued Application is hereby;made to the San Joaquin Locai-Health�-DI'w�ct for a permit to construct and install the work herein described. This application is made lin compliance with County Ordinancar No. 549 and existing Rules and Regulations: E � � JOB ADDRESS/LOCATIO f. i , E � ---1--- ------C CENSUS TRACT ----------- 04-.ner-DName i !t _ - Phone ----- Address p, , �- 'C-- --------• a - � --------------------�-�------ Q i r '3tY 1 ---------- ------------- ---- --------------------------------------------- Contracto r �J'vr�lf- ._ License # �9'r ---- Phone- I f Installation will se e: Res partmen-rHouse'�Commercial❑Trailer°0=xt Motel Other --------------- Number of living unit s:.____f.__ t i Number of bedrooms ______Garbage Grander Lot Size ___ _�� --------- \ftter apply: Public System and name ___-__ I-----------t-------------------------------------------- riva P ' to Chara11 cter of soil to a I tie dept, of 3 feet: Sand❑ Silt❑ Clay ❑ Peak❑ ,Sandy Loam •❑ Clay'Loam ❑ I 'Hardpan ❑ Adobe) Fill Material--- -- es, type h. t i If Y "'- r (Plot plan, sAowing size of lot, r�locat ' of system in Icitio6`1t a- Is, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: fNo septic tbnk.,or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT Ca SEPTIC TANK G'L ] Size------------------ ---------- Liquid Depth -----.�---------------- .- ac't � -6M T T,- �.� _ ..t P Y ype - CG1-e_----- Mafierial_ _' -Mo.<(C partments -_-- .-.__.... Dst nce to ne est: Well ---------1_ ------------------FbundationF_ ___-- _ --- Prop. Line .---------:----_--.--- LEACHING L1NE [ ] JNo. of Lines _ _.__ _________- Length of each line____._ ------ To Total Length - lam_..--_________ 'D� Box _ _____.. _ Type Filter Materia/ T- ------D&pth Filter Material ------- i1.[``............. �—:r!------Groperty Lin _ - -� Distance to nearest: Well PI_-_ Foundation _______ �_-__-_•_-_-_•-•_-_ SEEPAGE PIT [; ) e th =_ �--------- Diameter _ __ _ Number _ ___ --I i_,_------- I filled Yes No .0 Water Table Depth ------------------- --- 'Si R 73i p -----------------Rock Size 1/y.---� -------�---- � , Disttan'ce`to nearest: Wel). ------1 Ga Foldation ..-- --------- Prop. Line ---------------------- �.. � � ----- -------------------- REPAIRJADDITlON(Prey. Sanitation Permit# ----------------------------------- ------- Dater------------_-----------------___) Septic Tank (Specify Regquiii ments)------------------------ ------------------------------------ e � f Disposal Field (Specify Requiremets) --------------- -------------------------------------- #-------------- ------ ----------- -------------------------�----------------------\ --- - ---------------------- - _.._ - ------------ ----------------------------------------------------- -------------------- (Draw_existing and required ihe iio,n :n reverse side) I hereby certify that I have prepared this application and thawrk will be done in accordance'with San Joaquin County Ordinances, State laws, and Rules and Regulations of San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "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 become subject to Workman's Compensation laws of California." Signed ----- ------------ 1 ----- Owner �1.� - BY ------1-`-=--------- - -- ------------------- ------ --------- Title ------ � � ? (If of r an owner) { FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- - DAT1= '� =� BUILDING PERMIT ISSUED i----- -------------------------------- -------DATE ADDITIONAL COMMENTS F --------------------------:-------------------- -------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- ------------- ..., ¢ Final Inspection by: - - -------- -------------------------------------------- -------------------------Date - , SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M. ji