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FOR OFFICE USE: _D- APPLICATION FOR SANITATION PERMIT Permit No. ._/-�/ ..--- ------------------------------------------------ (Complete in Triplicate) �j -------------------------------------------- ------------- p bate Issued This Permit Expires 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 compliance with County�Ordinance N`o. 549 and existing Rules and Regulations: JOB ADDRESS�LOCATION --J/ -,fir" _:G ENSUS TRACT __� �`_-- -C7 Owner's Name - -,�� 4� - �Z- fes', .r--------------------------- -------Phone ----------------------------•- Address - -----. City _ p� ---------- Contractor's Name / ' 'xor License #� i�"° Phone��4_-9-4/4". Installation will 'serve: ResidenceApartment House❑ Commercial[]Trailer Court l❑ MotelOther ------------------------------------------- Number ----------------------------- -----Number of living units:---- Number of bedrooms -----Garbage Grinder __05_ Lot Size l / �'� ' 9 Private ❑ # Water Supply: Public System and name _-��.� _L1��f�---��---� -------------------------------------------- - ` Character of soil to a depth of 3 feet: Sand'❑ SiltO Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ Hardpan ❑ Adobe X Fill Material ------------ If yes,type ---------------------------- (Plot ---------------------------(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) p seepage pit permitted if public is available within 200 feet,) ` s NEW INSTALLATION: (No septic tank or �f { PACKAGE TREATMENT [ SEPTIC TANK, Size-- ------�---- ---------'----------- Liquid Depth ��t--- I Capacity�Z_Q _-,--- TYPeJ �'E°�� --- Material_ �3 ---_-- No. Compartments -- ---••-•------ --�—^ ------._Foundation _� ------------- Pro p. Line _ .�-:------ �' � Distance to nearest: Well ___________________ ___ ___ Length of each line_.��7_'________---.--- TotaE Length lh-_.- i LEACHING LINE pcJ No. of Lines •---"--'- ' - ---------- - / 'D' Box _. Type Filter Material/ 14 '-Depth Filter`Material /-� _------- ------ r Distance to nearest: Well ------— Foundation ---1/10 Property Line __s-------------------- SEEPAGE PIT Depth �+�~------- Diameter _,39�___ Number ___��-__-___________- Rock Filled Yes, No i❑ �.:tyy ' ~•--------------- Water ' I' Table Depth r-.--------------- Rock Size---~- - 1r � Distance to nearest: Well ------�------ ---------- Foundation X49---------- Prop Line --- -- ---- �x REPAIR/ADDITION-(Prev. Sanitation Permit# --------------------------- 3----------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) --------------- --------------------------- --------------------------------------------------------------- !---------------- a ------------ i Disposal Field (Specify Requirements) -------.------ - - -------------------------------- ----------------------- -- ------------------------- ➢ -------------------------------------------------------------- g -q - - F . -- -- - e -- . and that th e (Draw existin and required addition on reverse side) , -1{}hereby certify that I have prepared this applicationa 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: - 'I certify that in the performance of the work for-Which this permit is issued, I shall not employ any-,person in such manner as to become subject to Workman's Compensation laws of California." Signed ------------ --------------- ' � - - Owner * , B t Title ------- ---------- --------------- -------------r------ - -------- (if other th owner) F R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------------------------------------------------------------------• DATE -- �`'"_ _p'-7�_ -- ---- -- ---- BUILDING PERMIT ISSUED ------------------------f -----------�----=----- D ------------------------------- ----------- --------------------------------------------- - ADDITIONAL COMMENTS -- `~ .....A .C��- . i = ------------------ ---- ------------------ --------------- ------------ ------------------------------------------------------------.--------------------I--------------------- 7 Final Inspection b Date --1 ---� ----- - -/ P Y= • SAN JOAQU-IN LbCAL.,HEALTH-,,DISTRICT r u 0 1.'AR Rav_ 5M