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QR ONCE USE: APPLICATION FOR SANITATION PERMIT �7 Permit No. { _-� -•3 --------------------------- --------------- ------------ (Complete in Triplicate) --- Date Issued __��_.Z a_: z ----- ------------- -------------- ------------------- This i -- ------------ t -------------- ------------- ------ This Permit Expires li Year From Date Issued rict for a and he work herein Application is hereby madeto the o4com cornn eLocal Heith alth DytOrdinonce permit and existing Rules tand t Regulations: described. This application s ----------CENSUS TRACT ------------ JOB ADDRESS/LOCAT --� ------ --lX ----------- ----- -Phone_7-q_ Owner's Name ----- - ---- -- - ------------ -•CitAddress ------------------- L f ;.__ Y f y/ - S Phone`s -- lA --- ----'�-t-' ��r tom:"----=--- ------License # ---- -:�---- -------- ------- ---------- Contractor's Name ------------ ----- -•----- - - - Installation will serve: Residence�,Apartme t House,❑ Commercial:❑Trailer Court i❑ 1 ;Motel C]Other ----------------------------y-- ............ ---- ---- Garba a Grinder•____.---____ Lot Size �'P Number-of livingiunits:____/---..:-Number of-bedrooms ______----- g .._ . . � I ------PrivateA ��`Water ---------- S and and name ---------------------------------- ---------------------------------- k Character of soil.o a depth of 3 feet: Sand'❑ Silt fl Clay F1 Peat❑ Sandy Loam ❑ Clay Loam Hardpan Adobe' Fill Material ------------ If yes,type ---------------------------- ❑ E (Plot plan, sh wing size of lot, 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,) SEPTIC TANK �l }-r. _ Liquid Depth __. ---r----- _n PACKAGE TREATMENT C Si e_______-- -_-- a 7— No. Com artments ___----•-------------- t Capacity -- Type Mafienal �''-, p -- -•�. Fo�rndation'-----10----------_ Prop. Line __ •--- d -- �`� Distance to nearest: Well ___--_ ------ - f --_ Q e - _; v �. Length of each line--- LEACHING ine _ ------------ Total Length ----- ---------- ---- LEACHING LINE No. of Liries ____-____ __ '� Or --_De th Filter Materia! ----- -/8--l",------------------------- 'D' Box =_-_______-- Type Filter Material - ----- - ------- p 1 i i f__.:: •.4 f�-___:•..Foundation.•-:_,Grf?_�_._" Property Line. -- -----------------• I a••,-Distance-to-nearest:Weli _—_ --_-- ____-- Number --- -_--- - - Rock Filled Yes No 0SEEPAGE PIT Depth __:_ �_ - ---:- Diameter - -- 1_61__: Rock Size _i? Water Table Depth.---------------'----------- , . �- .--=-- Distariceto nearest: Well ---------�-- 11 =----Foundation ---- _-- Prop. Line -- -------•• w . ` ' --------------- -- Date ------=---- ---------------`------- REPAIR/ADDITION(Prev. Sanitation Permit# _------- ---- Septic Tank (specify Requirements __-----: -- ------------------------------ --------=---------- i : I r, p ---------- - �j�,✓-------- - - Disposal Fief - -- pecify._R quirements) =--------------------- ---------- - --------------- --- -- -- ---=- -------------- --- ---- ------- (s�u=" F ----- --------- -- -'- -------------------------------------- - ----- 1 -- (Draw exist g and required addi#ion on reverse si e I hereby certify that I have prepared this'application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws,'and Rules.and Regulations of.,the_Sa6h6'aquin-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, 1 shall not employ any person in such manner as to become subject to Workman's'.Compensation laws of California." S jV, caner ------ -------- Signed 7__ I ---- --------------------------- ---- - --------- -- By ------------ ----- (lf other# owner FOR DEPARTMENT USE ONLY - --- ------------------------------------------------------- DATE == ------- ---------------- APPLICATION ACCEPTED BY .__. __ ------- -- - ----------DATE.--:`------------ ----------------------------------------------------------------------=---- BUILDING PERMIT ISSUED ----------------- - -------------------------------------- ADDITIONAL - -- ---•------- -------•ADDITIONAL COMMENTS �--.-",.--------------------------- - ----------- -------- ------------------------ .. �- - _-- _-- -- ""-------------- ------------------------------------------------ ---------------------------------------- - ------ --------------- ------------- ------------- -- -- ----------- i -1------ ----------- ---- -- - -- ------ --------- ------- - - - - to -- Final Inspection by: _ --- - -- - ---------------------------- * SAN JOAQUIN LOCAL HEALTH DISTRICT F H 4 1•'68 Rev. 5M