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FOR OFFICE USE: { APPLICATION FOR SANITATION PRMI .; .e s - `` pp� ----------------------------------- --------------- Permit No.C�1l._:__��---___-. - [ omple4�in Triplicate) - -------- ----------------------------------- Date Iss11 ued ��_�.---- -. i This Permit Ex p.ares 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in com1'a ce with County Ordinance No. 549 and existing Rules and Regulations: Ft R[_ l JOB ADDRESS/LOCATION M ��xa /�G�?�-----CENSUS TRACT - Owner's Name ._ - Phone ��.�(/ltd---l�/�_Ch!�11------------------------------------------- ---•----- - - Address _-_ . _-____. Cites' Contractor's Name j.1�_�-------- f�------------------------------------- -------.License #1,2 29"5---- Phone Installation will serve: Residence Apartment House F1 Commercial :❑Trailer Court ',❑ Motel ❑Other .-�_ ----------------------------------------- Cot � ._ • •••- Number of living units:_sNumber of bedrooms -�----_Garbage Grinder _,640.- Lot Size ------- _ __ _. __� Water Supply: Public System and name ---------------------------- Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy.Loam ❑ Clay Loam;❑ Hardpan ❑ Adobe;V Fill Material ------------ If yes,type -- ------------------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) i NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ' I Size- %) --- --------- ------------ Liquid Depth __'V--------. PACKAGE TREATMENT [ ] SEPTIC TANK'{i Capacity 000_i'W_ TypeOW 19 Material No. Compartments --.-- Distance to nearest: Wel{ -- V.___�-------------------Foundation __/_0__---------- Prop. Line --- --f___:_:---•-• (� . i LEACHING LINE C�'. No. of Lines --- -------------------- Length of each line------ __a------------- Total Length ----------------- 'D' Box �Q---- � Type Filter Material 1�r"a -___Depth Filter Material _/ ----------------------------•-.---- � _ s Disfiance'to nearest: Well --------------- Foundation -_-4 C--- ---- ----- Property Line, ��_ ............ SEEPAGE PIT [�} Depth _'k-5--_ ----- Diameter �3________ Number I Rack Filled Yes a No 0 Water Tai b1e Depth __ p _ Rock Size �__ ✓_�-- ----•.-------- ------- Distance tI nearest: Well - - d-- -------------•-------=Foundation --/_O--- ------ Prop. Line -- ..--- I REPA IR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------_-----------------•-----Septic Tank (Specify Requirements) ---- --------------------------------------------------- ---------------------------------------------------------------------------.-Disposal Field (Specify Requirements) --------------------------------------------------- --------------------- ------------------------------------------ --------------- --------------•--------------------- -------------- ------------------------ ------------------------------------------------------------------------------------------------------•---------cern -that I have re '--- -- --- - {Draw existing and required addition on reverse side) I hereby certify p p red 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 licen- sed agents signature certifies the following: F.y , in such manner "I certify that in the performance.of the work for which this permit is,issued, I shall not employ any'person as to becom sub' ct to Workman's Compensation laws of California." Signed _ . i------------------------------------------------------ Owner ----------------------------------------------------- Title ------ ----- --------------- -------------- ------------------- (If other than owner) fAIFOR DEP RTMENT USE ONLY APPLICATION ACCEPTED BY ---- DATE ---- -' - -�.r-- -- -.... BUILDING PERMIT ISSUED ------ ---`-------- = DATE -- ADDITIONALCOMMENTS - -'-------------------------------------------------------------------- -------------------------- --------- -------- -------------------------------- i -- --------------------------------- -------------I------------- ------------------------- --------------------------------------------- -- ------------------------- ------------------------------------ -------------------------- ------------------------------------- -------- ------ -------------------------------- -- -- Final Inspection b -------Date -- �a ' - P y SAN JOAQUIN LOCAL HEALTH DISTRICT n. E, H. 9 1-'b8 Rev. 5M