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FOR OFFICE USE: Fes' APPLICATION FOR SANITATION PERMIT Permit No. ��""�73-- ---- -- ------------•-- --------- ------- (Complete in Triplicate) /Cs�j,L -------- P Date issued -------------------- This Permit Expires 1 Year From Date issued an Joaquin Local Health District for a permit to construct and install the work herein Application is hereby made to the S liance with County Ordinance No. 549 and existing Rules and Regulations: described. This application is made in comp OsaI10 ,, . --=--_----3--------------_-_-_-_- _ JOB ADDRESS/LOCATION CENSUS TRACT Owner's Name A/0 ----------------------- ------- -- ----- -�-------- ----__-_.-Phone Address _ I�_ C 10?1'/p .a ------------------------------•- Contractor's Name : City . A_ �. i License # ---------------- ------- Phone ------------------------------ _.D.u/2�r- -------- ------ -- - --- ------- -------- -----.-- - -. � Installation will serve: Residence pq Apartment House❑ Commercial ❑Trailer Court [I Motel ❑Other -------------------------------------------- I -O---- Lot Size aC! 5-------------------- Number of living units:___/------ Number of bedrooms __,2------Garba_g e Grinder s ____Private Water Supply: Public System and name - ----------- --------------- ------------------------------------------- Character ------------- --------------------------Character of soil to a depth of 3 feet: Sand'❑ Silt❑ clay .❑ Peat❑ -Sandy Loam '❑ Clay Loam ❑ #Hardpan ❑ Adobe;® FillMaterial ------------ if yes,type _______ _ i [Plot plan, showing size of lot, location of system in relation tcr wells: buildings, etcmust be placed on reverse side.] N NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feetj PACKAGE TREATMENT [ I SEPTIC TANK. l Size---------------------------------------- -------- Liquid Depth ------ aterial---------------------- No. - Compartments --- - Capacity _�y.��Q------- TYpe Pro Line SIL � � p rOTAO"Distance to nearest: Well _-/__�-------------------------Foundati n'. 'S ---- --- P _ - l T1pF , �y .�-�-- ---•-------- I I � tS nth of each line-__s �_ _________._ TOTot Length ._--�-- - LEACHING LINE No. of Lines ---- -- -------- 9 ie D' Box" -- Type Filter Materia! oc^.____Depth Filter Material l 7` __-____-___ Pro err Line tion p Y -j to nearest: We - 7---- FNumb k Distance - - k Diamete = ----- Number ---------- ------ ---------- Rock Filled Yes ❑ No ❑ SEEPS PIT [ 1 Depth __ k----- f„. Water Table Depth ----------------------------------------- ------Rock Size ': Distance to nearest: Well -------------------------------- Foundation ---------------•---- Prop. Line -------------------- • 3..5 -------- -------- Date �_3�---�-�------------) t REPAIR/ADDITION(Prev. Sanitation Permit# --/- - -__ t _ ------------------------------•.-------------- Septic Tank (Specify Requirements) --------------- ---------------------------------------- -- ' ------------------- ---------------------------------=----- Disposal Field (Specify Requirements) ---------------------- •------- ---------------------------- ---------- _______._.._________ ______________________ _________--------------------------____________________________________________________...____---------- I (Draw existing and required addition on reverse s!del I hereby certify.Fthat I have prepared. this-ap-plication and that the work will be dove in accordance, with San Joaquin *” County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or licen- sed agents"signature certifies the following: h manner "1 certify that in the performance-of the work for which this permit is issued, 1 shall not employ any person in sue as to become subie to Workm 's Compensation laws of California." k Signe ---------------------------------- d - --- Owner Title ` BY -------- ------- '-------- --- [If other than owner) FOR DEP4gTMENT USE ONLY APPLICATION ACCEPTED BY __ --------- - ------------------ ---- DATE _ -- ----- IBUILDING PERMIT' ISSUED ---------- ------ --- -- ----n---- ---------------------------------------------------------- -------------DATE - ------- -------- -------- --------•--- ADDITIONAL COMMENTS ----------------------------------------------------------------------------------------------------.----- ------- - r -------- ------- ------ --- ------------------------------ ---------------------- --------------------------------- --------------------------------------------- ---- --------- - / ----- - -- - -�`--'="--- ----- -- ---- -- --- -- ---- ------ - -------- - - Date -------- - -- ----------- -Inspection by: __ -- --- - -- - --------------------------------------------- Final ------- ------- -------- -- - _ ®.K.P. �rrn'. ^-r�� 'SAN JOAQU N- LOfA�L, HEALTH DISTRE f o- 2`t-7 7 C JC. �,. fso.'ar� � S-r l t E. H_ 9 1='68 Rev.. 5M. ,f