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FOR OF FIC U,SE: ------ ---_ -- _-- APPLICATION FOR jSANITATION PERMIT (Complete in Triplicate) Permit No.. _� ___ -a 3�r3o - ------- This Permit Expires 1 Year From Date Issued I f Date`lssued Application is hereby made-to-the=San-doLocaf Health District for permit to t} s ,-q- constructyancl install the work herein described, This application.is made in compliance with County�Ordinance No:_549Fand,existing-Rules and Regulations: AF JOB ADDRESSAOCATI N ._ _:__::: `------------------------- Owner's Name . . . CENSUS TRACT - �✓ f 4 '�, 'r ---------------- ---- Phor Address �~ � �9� -- - Contractor's Name __.._ "� y -----,._. city -- - - -- - �� '`✓"'--"`". == ------ License #af Phone-/1e7 -�~ f -' Installation will serve: Residence Apartment House❑—Commercial ❑Trailer Court ;❑ Motel ❑Other _________-_- Number of living units:_______.- Number of bedroo ms __Z-_-__-Garba a Grinder 9 /�Q Lot Size l� e ----- Water Supply: Public S stem and npme _ 1 y AP Y: Y --- ��rs-f,/•��--'--- - --�_.-----Private ❑ �M - ---------------- Character of soil to a depth of 3 feet Sand❑ S I't❑ Cla '' '- P ❑ Fill❑Mdterial E] Sandy Salff d esoam�❑ Clay Loam Hard a�""n "�V""""Adobe Y tYP ------ tod (Plot plan, showing size of lot, location of system in relation to w�Is, buildings, etc. must be placedon reverse side,)- NEW INSTALLATION: fNo septic tank or seepage pit permitted if public sewer`is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK, "ff z Size- -- fC `�----------- � Liquid Depth :: Capacity] Fes----.: Type Material` .,... f �I �' II Com partmentto nearest- Well ______ " -Foundation - ------------------------ -- LEACHWG LINE No. of --,�=-------- -- Prop. Line _�f_-______"__-- Distance �IQ Lines ---------------- Length of each line- -_ " D' Box g �Q ------ ----- Total Length Zt9Z7.-- r � ,�_- Type Filter Material Depth Filter Material i v p -------' -------------- A Distance,to nearest: Wel! _-'—'-'----------- Foundation �� ` ' f . Property Line _�- SEEpAGE PIT [ j Depth �, # i =-�_ p , Diameter Number .---� ------------------- Rock Filled t Yes ' No 1❑ `� { Water Table Depth `" Rock Siz iop to nearest: Well __-- --------" � ' Foundation _ftp_------ Prop. Line �®----- REPAIR ADDITION(Prev. SanitationPermit=# _________________ � t ,:I ------------------- Date ) Septic Tank (Specify Requirements) _----___..__"_______________""___ -, ---------•----------------------•------- -------- .----�- Qisposal Field {Specify Requirements} ________-_-_ --""_"-" ------------------------------------------------------------------------- _ ------- i = = - ---------------�------- ----------------------------- ". L. ------------------------- - ---------------------- - --- ------- - ------- --- ( , J .~, Draw existing and required addition on reverse side} j ---------------- ---------- I hereby certify that I have prepared this application and that the work will be done in accordance wit San Joaquin. County Ordinances, State Laws, drid Rules and Regulations of the San Joaquin Local Health District. Home owner or licen-r sed agents signature certifies the following: _ "I certify that in the performance of the work for wh'ith this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Com Compensation laws of California." Signed ---.----- p jj ----------- i --- -- -------- --------=-------'"`".-""Owner BY ------------------------------- ------JTitle w -- - (If of than owner) ----------- FOR -_---- _ - it FOR DEPARTMENT USE ONLY t } !P PLICATION ACCEPTED BY ._. /� _ e DATE _._.•.3-/1 7 -- BL1iLDING PERMIT ISSUED -____ _ -------- ------- ",tor -----DATE ------- ADDITIONAL COMMENTS _-3 _ ------------------------------------------- - ----------------------------------------------- -------------------------------- ------- ---------------------------- -------------------- -------------------------- dIP Ay ----------------------------------)----- --------------------- - ------------------------------------------------- - --°----------------------- ------------- r ! -- ----- --------- --------- ---------------- in�al Inspection by: -- ----- 3"---------------- ----------------- ------- •- - �- - -----------Date ----- SAN JOAQUIN LOCAL HEALTH DISTRICT t . . ' E. H. 9 1-'b8 Rev. 5M