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- FOR OFFICE USE. �....»__ - .. _ APPLICATION FOR SANITATION - --------gyp - -------------------------- (Complete in Triplicate) Permit No. 11 �r ii t --- ------ --- This Permit Expires 1 Year From bate Issued Date Issued _.- (--1-70 t4-1 /3 f-- 3 �0_03 Application is hereby made to the San Joaquiri`Local Health District for a permit to construct and�,insiall the work herein describe Thrs application is made in compliance wits Count Ordinance No. 549 and eVN� Rules and Regulations: 2-t �., �t L2 Y JOBIADDRESS/LOCATIO Owner's. Name (t_ ,$"' � '� US TRACT -"- __._ e ---------------- Addow r ess -_-s/ ,• +-- �,--- -- hone --- P ,� --------- ------- Cit ContrName "_ _ y �` ------------------------------------- actor'sdl Installation w Residence: . A ent H License`#/Ri �� ,--_- Phone f ----------------------------- ill serve; Residence p House❑ Commercial :❑Trailer Court ';❑ A Motel ❑Other ------------ --------------------------- Number of living units:----I" Number of bedrooms g / +sem--""-."Garbage Grinder l -__ Lot Siz ` -_"�Ci" W er Supply: Public blic System and name --"" __ - ----- _ Private ---- Character o sbil,to a depth of 3 feet: Sand' -"" +1 ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 4 Clay Loam:[ ! Hardp4n ❑ Adobe' material ------------❑ Fill If yes, type�------ ----------� - � . .� {Piot plan, showing size oflot, location of system in relation to wells, buildings, .etc. must be placed on reverse side.) NEW INSTALLATION: {No septic tank,or seepage pit permitted if public sewer is available within 200 feet,) `, PACKAGE TREATMENT [ ] SEPTIC TANK�(j `� F� / } 4 . s Size- ---------------------- liquid Depth / Ca acit Materiale' A1�_.__" No. Compartments —_•______: "" ' P Y�'=� ----- TYPe � - f Distance to nearest: Well 1 ----------------------Foundation -/ Prop. Line ' ) lEACHING'LINE ------------- - No. of Lines '/ „ Length o each line., -----i- ----- Total Length A/P---- 'D' Box ---•- 4� /&-" -- Type Filter Ma/tial, `- ,_p_ Depth Filter Material 'V -------------------- - - „� � II Distance to nearest: Well !�� ""--- Foundation -- ------__"--- 'T SEEPAGE PIT ------ Property Line. 0 � . p tY . [ 1 Depth ------------ ------ Diameter Number -____-- -- --�� -- Rock Filled Yes 0 No I! Water Table Depth --------------- Rock Size ----------------------- Distance , REPAIR ADbITI to nearest: Well ----------•------------ Foundation 1, ------ ------- -i0-�Prop. Line "..----------=�---•-' 1 ON(Prev.[PreySanitation Permit# -------------------------------------------- Date ---------------------------------} �� Septic Tank (Specify Requirements) __ ------ -------------------------------------------------------------------- Disposal Field (Specify Requirements) ----------•------------------•---------------- ------------------------- ---------------------- --------------------- ----------------------------------------------------------------------------------------------------------------------------------- ------------ -- ------ (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 I I County Ordinances, State laws, and Rules and Regulations of the S San Joaquin p sed agents signature certifies the following: an Joaquin Local Health District. Home owner or Iicen- "I certify that in the performance of thework for which this permit is issued, I shall not employ an as to become subject to Workman' Compensation laws of California." p y Y person in such manner Signed ---- I. ------------------- Owner ----- -- ----------- Title --------- o�than owri�r) j -------------- a r FOR .DEPARTMENT USE ONLY � APPLICATION ACCEPTED B = ---- --------------------------------------------- �f x 7�J UILDING PERMIT ISSUED __-- -: ---- RATE ---_-- ----- DATE -. ` = ADDITIONAL COMMENTS _. _ _" _ -- I --------------------------------------------------- ----------------------------------------------=-------------- r f ---- -- --- --- ----- ------------------- --- --------------------- ------- ----------------- -- ----------- -- ------------------- - -------- -------------------------------------------------------- ---- - ----- -- Final Inspection b i-"-_""-_" """" " `fir---- ----------------- !- 7 I - - ------- ----.Date --- -- --- --------- - SAN JOAQUIIv LOCAL WEALTH DISTRICT E. W. 9 1-'b8 Rev. 5M. � .