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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------- -------------------- �� Permit No. -" I .-.� _. �, , , .- - (Complete in Triplicate) 7I-_,.3_7u . ---------=--------------------------------- ------------- ___________________________________________I------------ . 4/. This Permit Expires 1 Year From Date Issued 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 compliance with County Ordinance No. 549 and existing„ Rules and Regulations. JOB ADDRESS/LOCATION .__ T _r _- -- -------AWFF 4 -------- �I ---CENSUS TRACT --- `-- -------- Owner's Name -- ="-- A-M-P-S------ I'`,F?0f m__ [_ ----S R1n�'�.-C = 'Phone ------------------------------------ � ,� �i-iFJ�}_` - . . City --'---------------------------- Address ----- _-- -- -- �tyr�I `R�+ E . Contractor's Name` 'en(J,I9VE_P--------------------------------------------------------License # ------ ----------------- Phone ------------------------------ Installation will serve: Residence ❑Apartment House❑ Commercialrailer Court ',❑ Motel ❑Other -----------------------------------------/----�� Number of living units:--- Number of bedrooms.,'-_Garbdge`Grinder ___-` Lot Size __/1 MEA6�_____.___ .ti n ; 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 '❑ Fill Material 1-c--0--- If yes, type _______________ (Plot plan, showing'size of lof location of system in relation to' wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitfed if public sewer is available within 200 feet,) PACKAGE TREATMENT f ] - SEPTIC TAN -.Size _4..5 X_�. _X ______________ Liquid Depth -- -7�--” " --"- QKy '� -� _.__r _ -NU Capacity � T � -- si- OCRT— No. Compartments � �1eial �+ - Distance to nearest: Well ______� __ ____________Foundation _J(d -� "�_____ Prop. Line --------"--"" le LEACHING LINE No._of,Lines ______ ! - ------ --- Length of each line_.____. __ __ ____ Total Length ______ Q D' Box�r6_____, Type Filter Material --Depth Filter Material ____ ________________ Dista ce to nearest: Well ------- -----""" Foundation _/ -� - Property Line __ SEEPAGE PIT [ ] Depth, ____________________ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ ~Water Table Depth ---------------------------------------._-_-------Rock Size -`:---- - ° CDistance to nearest: Well -----__---------------------------------Foundation ____________________ Prop. Line ...................... REPAIR/ADDITION(Prey:-Sanitation Permit# ________.__-'_____________________________ Date _______________ ___} - -Septic Tank IS ecifY Re uirements) ------ � ----------- 6-------- � .. :=---------- ^' ` ' Disposal Field (Specify Requirements) i,,-r� ____--CQ1� f �l__� --- ��- ----- -------------------- - - J 1 (Draw existing and required addition on reverse side) I hereby certify that.I have prepared this application and that the work will be done in accordance with Sart Joaquin County Ordinances, State Law's, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify t in the erfoK,� of the work for which this permit is issued, I shall not employ any person in such manner as to beco sub' t to WCo pensati.on laws of California." Signed ----- 2 -------- Owner -------------------------------- - BY ------ -- P---- ----------------------------7 C�---- Title ---------------------- - r (If other than owner " FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - --� `-- -�--------------------------------------------------------- ---------------- DATE --- -- -- ---------- BUILDING PERMIT- ISSUED ---------------=--------- ... . _DATE --r-._-=_-._:---_-: ADDITIONAL COMMENT ------- ________________________- - ------ ________________________________ __ __________ _________________________ ___________ __ _ _______ _ _ _________ __ _______ ______ Final Insp - / _ _� ✓ ------ ------ - __- ------Date ---- a_- -- -------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M