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f FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------- Permit (Complete in Triplicate) - --------------------------- ------ - -- - Date Issued--5 -�'`� ------------ --------- 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 No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC --..f1ro°%.��f ' ------ ---- '--CENSUS TRACT------- ------------------ - " r e ------,- Owner's Name----- -------- - = ----- 9 Address-------- r-- - ------ City C�" ZiP �� 7J Contractor's Name � License #- zZ Phone Installation wi11 serve: Residence [i Apartment House.❑ Commercial ❑ Trailer Court ❑ g. Motel ❑ Other--------- ---- i- Number of living units:-- 4-_----Number of bedrooms.._y_-.Garbage.Grinder "Lot•,Size------ -""' -------- 1 ` t Water Supply: Public System and name--- --------------- ---- --/--- ----.- ------------- : ----- Preva I . Character of soil to a depth of 3 feet: Sand Silt :Cla Peat Sand Loam L� Clay Loam p - � ❑ , Y Y 0 Hardpan ❑ Adobe ❑ Fill Material-- -°- -.--If ,yes, type__? --.-_'-_--_ ---. - i (Plot plan; showing size of lot, location of,system in relation to wells, buildings,'etc.mus# be:placed-on reverse side.) NEW INSTALLATION: ,(No septic tank-or seepage 'pit pitted if p6151ic sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TAN'K' [ ) Size:--:-_--------- _--' - --- --:----Liquid Depth:.--- ---- �CapacitY: - ---- -,:T_y.peaterial -------No. Compartments------ ---- --- Distance to nea� { 11 l rest: Well ---- -I F- i _Foundation �; Prop. Line. = i "�`� LEACHING LINE Nob f Lines: ._ S :- - Length-of each lm`e.,.:_` :'--------------.r. Total Lengtr._ {{ + 'D' Box--!---------Type F _ Filter Material ---- - --.Dpth Filter Material _• t: --------- ----'L --.--- ------- ----" --------- ----- Foundation ----- -------_- -_-Pro ert Line Distance to nearest:-Well °-------------------- P Y ------ -------- ------ - '� Number r ---- Rock Filled Yes ❑ No ❑] SEEPAGE PIT I ] Depth----:. - Diameter- ---- - w` v �'. _ ./<: '�',�1�'-ly•SFT a.3'�:J'!��7�+fI -- �v� - i Water Table Depth ------ , --- -- --- - Rock Size ; "�� • , Distance'to Weare'st'^Well''` ? __ -F--tion---------; -_-t'-.;-.Prop. Line--: - ----------------- II ' REPAIR/ADDITION (Prey:Sa itatibn Permit;#----------------: ;= ---�--------'4__-_-:Date-- = ` ---------) y f fF ! 5 P I - -------- ------•---------- ---------- Se tic Tank (Specify.Requirts)---- ; > - - ------------- -- --- ---- --- ----------- ----- ----------- Disposal Field (Specify Requirements) _ - , ,, `• ------------------------- -• - 7 t "(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 San Joaquin County Ordinances, State Laws, and Rules .and Regulations of. the Son Joaquin Local Health_ District. Home owner or licensed agents signature certifies the following: " certify that in the performance of the work for-which this permit is issued, I shall not a ploy any person in such manneras I Y to become subject to Workman's. Compensation- laws of California." Sig ned l ; - ; Owner er Titl: B -- --- ---- t s s (if other than.owner) FORMEPARTMENT USE ONLY t APPLICATION ACCEPTED: BY- DATE "z`a DIVISION OF LAND NUMBER. = - - DATE ADDITIONAL COMMENTS- ------- -------- . -- ----- _ t .. --------------------------------------------------------- ------------------------------------------ ---- -------------------------- ---- ---- --- ---- Final:Inspection b _ - ---------------Date '.. t F&s sibs REV. 7176 3M EH 13 24 SAN JOAQUINI OCAL HEALTH DISTRICT