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w FOR OFF�7, E USE: c. APPLICATION FOR SANITATION PERMIT �Q-. Permit No. _ _______ 0 ---------------------------------------- ---------------- i (Complete in Triplicate) ------------------------------ p I—' Ddte lssuedld'0.�"- t� This Permit Expires 1 Year From Date Issued i ____ ---------- 1 TI { Application is hereby made to the San Joaquin Local Health District for a permit to constructed install the work herein l described. This application is made in compliance with County Ordinance No. 549 and existing Rule's and R�ula#ions: M C --..CENSUS TRACT -__- --y- ------- JOB ADDRESS/LOCATION . _2-693-1--------�---------�'`A M1 Ownerf�� 's Name ----- -v4_1 -L.t✓9-------------- Q '.Phone `� S M _1.7_i �� _. City -------P-�"-' ---- --'--------- Address ---- -------- ; Contractor's Name `Tl'_ .ST4CN ---------License # -------------------- -- Phone ------------------------------ Installation will serve: Residence ElApartment House❑ Commercial ❑Trailer Court i❑ -- I Motel [-] Other ----------------------------- { -- 1 cif J Number of living units:__- -i�___ Number of bedrooms _______Garbage Grinder NiLot 5�ze' _ ----- -. - Water Supply: Public System and name ---------------------- ----------•--------------------------------------------------tir Character of soil to a depth of 3 feet: Sand❑ Sil E] Clay ❑ Peat El Sandy Loam1{]; Clay Loam P� Hardpan Adobe ❑ Fill Material If yes,type ------------------------ --- i {PI'ot plan, showing size of lot, location of system_ in relation to well s;-buiidings,.etc. mustibe-placed on reverse side.) P p P P '' uicl de th 7- `r ' NEW INSTALLATION: (No septic tank or seepa it permitted if public sewer is available within 24O feet,) PACKAGE TREATMENT [ ] SEPTIC TANK;[ Size---� �� X � Liq : p a� �4C> CAM5T- citerial--�13N�l4 No. ,Compartments --_ � Capacity ---- ----- ---- Type i'R E - � r � _ Foundation -- t0--_r� Prop. Line stance to nearest: Well -------�----------------------- I , ____._-__ Length of each line____--- 5� ----"----•- No. of Lines 5.-- --.------iTatal length ---/570--1 LINE [ ---- --- - Z .-, - ---------------------- ----- i 13' Box Fs- Type Filter Material _ 0 Cf -Depth Filfier�+atena}l _-_ - --- -- t ' ----�Qa�' --------- Proper line Distance to nearest: Well Foundation - Nvmber -__---- ------- Rock iIl'ed Yes o •0 } SEEPAGE PIT Depth - -r{1--- Diameter _ a. --- , , r, Water Table Depth 'i; ------------Rock Size / ` y .Z..�_ i i 1 fDistance to nearest�Well _.__�� -----'��'----------Foundation --` -- -- __-- Prap. Line 5--------- REPAIR/ADDITION(Prev. Sanitation Permit# ---------- --------- ----•---- -------- ate ----- 6 ------------------- - ------ -n �ilrl`- � — -# - -- --- ------------------------- Disposal ;----------• ------------�` --------- - ---•--- I Septic Tank (Specify Requirements) ----�-- -`,-------------- --------------------- ---------- "--- f d 1 .-- - _______l______.______________ Disposal Field (Specify Requirements ---- ------------------- --------------------------------------3"- ; 1 4 tk,j f in I ,i ---- ------ --------------------- -- ---- ----- ----- - - ---- ---- ----------------- I >> _- ---------- -- ----- --- -- - -------------------- 1 '!_ - _ (Dravu._existing..and.-req.uired addition on reg erse side) ! I hereby certify that I have prepared this q� plication and that the work wi�l be done i>, accordanie with San Joaquin ' County Ordinances, State Laws, and Rulesand Regulationsf the San Joaquin Local Heh"District. Home owner or licen- sed agents signature certifies the following: "1 certify that in the performance of the work for which this permit is issued„l q all not employ any person in such manner as to become subject to Workman's Corn ensati.on laws of California.” p f Signed - Owner I Title `- ---------- -------------- ----------------- (if other than own r ; 3 t _,�_y f z;,FOR-�.DEPARTMENT USE ONLY y� _.._ •--�—;r� DS✓ 7 -�`------ ATE H APPLICATION ACCEPTED BY ---__�f I -t�=-;-� _ - -------- ------------------------------------------- - ------- - BUILDING-PEI fi17"15SUEII'� - - '-='- - -' - —�----- --�= -------�= ADDITIONAL COMMENTS ---------- - ------------ ----- ° - —..--I ; --- -- -- ----------------------- -- --- --------- _ --- - ------ ------ -- ------ 7 Final Ins ------- Date SAN JOAQUIN LOCAL HEALTH'DISTRICT 4 E. H. 9 1-'6B Rev. 5M '