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YFOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ---------- ---------------------------------------------- (Complete in Triplicate) -------- ----------" ---- ------- -------------------- Date Issued I This Permit)Expires 1 Year From Date Issued _- Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: !8,&-� l -~ R ze6 j-- lsa —0 JOB ADDRESS/LOCATION .-----.--+5�,-- ° '�' r� ' ` ` CENSUS TRACT -------------- Owner's Name -0b;V_"��`'_ 014 - -_Phone me? 1�.__... - Q ��`''- -------------- City ------ Contractor's Name _��_------==- ----------- ---------- ----------- .----.-----. ----- ------.License # ------- - ---------' Phone -------•---------------•- installation will serve. j Residence ❑ Apartment House❑ Commercial ❑Trailer Court Motel ❑Other -------------------------------------------- Number of living.units:...... ---__ Number of bedrooms -_- ____.Garbage Grinder ------------ of Size ___________________----------------- Private Water Supply: Public System and name ------------- t Peat Sand Loam Clay Loam ;❑ Character-of soil to a depth of 3 feet: Sand-F] Silt❑ Clay ❑ ❑ Y ❑ � _ Hardpan ❑ Adobe' Fill Material If yes,type -------------- 1 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) i it ermitted if public sewer is available within 200 feet,) } NEW INSTALLATION: (No septic tank or seeps p p P J SEPTIC TANK _-________ Liquid Depth ____ � PACKAGE TREATMENT [ I � Size_-IQ_��X-_`f______._.-.- �---- -- -- � Material_��-✓-e�P- No. Compartments __�=f-----�---- � ` Capacity s4cL2 " T P Y `-�� YP �- Foundation _ -'v"�--------- Prop. Line ---------- ------- stance to nearest: 'Well __3-C F l . . l i i ' ----- Total Length LEACHING LINA ' No. of Lines __ ----------------- Length of each line-_-------�- -- 9 —� Type Filter Material Depth Filter Material _________1 ----------------- .......... G I 'D': Box ��-8� yP a ,i - � - � - � Founds#ion --- ---��--�---- Property Line. �---•-•-------••-•-- ' — -- Distance to nearest: Well -3®�� _ �X , Depth _- Diameter �(----- Number _-----:Z__ ______--_ Rock Filled Yes No i❑ SEEPAGE PIT [l�]� �P -- � -� - �" Table Depth y0 Rock Size --------------------------- ------- ----------------------- - - Water Ta -------- ---------------------•---------------- " Distance.f l Foundation __l'e? ------- Prop. Line _ ----------•------ o nearest:.Well --- 1>---------- = ' r�. I -- Date ---------•-------- --- ---) • REPAIR/ADDITION(Prev. Sanitation Permit ________________"_-_________"-_____-: 11 _ _ v --------------------------------------------------- Septic Tank (Specify Requirements) --------_------------------------------ ---------------- ,,; +� Disposal Field (Specify Requiremenfis) ---------==-='-_---__--=-=--_-•-------•--'--`----- --- ---------------------------------------------------- ------------------ Disposal ----------- ----------------------------------------------------•----------------- -------------------------------- �- . ___ - ------------------------------ I hereby- ereb certify that I have prep� (Draw existing and required addition on reverse side) ----------- --- -11- - a application and that the work will be done in accordance with San Joaquin ared this 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 bec a subject to'Work n's CompensatiAws of California." Signed __ ------- ------- wn --------------------- By ----------------------------------------------- ----------- itle ------ ---- ------ ---------------- - ---------------------------------- (If other than owner) OR DEPARTMENT USE ONLY ( APPLICATION ACCEPTED BY ------- -Z - r ----------------------------------- DATE =---------------- BUILDING PERMIT ISSUED -------=---=--- ------------------------------------------------- --- ----------------------------------- DATE ADDITIONAL COMMENTS ---------- ------------------------------------------------------------------- -- - --- ------------------- ----------------------•=----------•---------------- I � --- --- ----------------------------------------------------------------- ------------------------------------------------------------------------------------------------- -- " --------------------- � � Date --------------- -- Final Inspection b SAN JOAQUIN LOCAL HEALTH DISTRICT C E. H. 9 1-'6$ Rev. 5M __