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f • t Y F6R OFFKE USP.- APPLICATION FOR SANITATION PERMIT ------------------------ -------- Permit No. -- -------------- - � (Complete in Triplicate) � , ----------------------- �r Da#e Issued --------------` --~�' ----- ----------- ----------- ---- This;Permit Expires 1 Year From Date Issued Application is hereby made to the San oaquir� Local Health rstr-is# for= a-.permrt-to construct and install the work herein Regulations- described.This application is made,in compliance with Cou" ty Ofdnance No;549 and existing Rules and Reg/u�lations: ter z► �Z? B�K$7d �- l RQ.P CENSUS TRACT ----- /---------------- 9 iOB ADDRESS/L'OCATI N�z_.' --- T �HTH -� �t ".'".. hone ---------------- 14 NORM-- nl_p_f3_ _�- - Owner's Name _ N g o ------------•------ v o. . * 4 R�_ _�_ �.��_ Cit �- - �- -- - ----- --- --- -- Address _ -----•--' Y -- � �r_r h ------------ - DlNI _ j -._ --License # " —=„P one L Contractor's Name __._ -. � ----- -------, I : Installation will serve: Residence [q-Xpartment House,[:] Commercial m❑Trailer Court 1:1 /,� d 7'�''Motel ❑Other I --___Garbage Grinder -------- 170 Number of living units:_.____-___ Number'of bedrooms -- -+�- -- Lot Size ____ ____--- ---- ------------ - i C�r� AT F • -- Private ❑ i -1--1qTHRQP---- •._ Water Supply: Public System and name, . ; Character of sail to a depth of 3 feet: 'S;and'®/�ilt❑ Clay ❑ Peat El Sandy Loam [] Clay Loam ❑ y HaFdpan ❑ Adobe❑ Fill Material _ - if es, pe __--_---------------- - buildings, etc. must be placed on reverse side.) (Piot plan, showing size of loft, location1,. of system in relation #o wells, , NEW INSTALLATION: (No septic tank l`or seepage pit permitted if public sewer is available within 200 feet,] \ ► r X-- ---- __-- Li Liquid De th _- ---ZZ-------•- G` # PACKAGE TREATMENT [ I SEPTIC TANK� Size--- Compartments q p �O+�•- r ..�`�,f�fl�}$. Material.__�/�ICe��_ fo. Compartments -.----•----•-•------•- Ca acifi s ''' P Y - ----� -ti-•;- YP - istance to riearest: Well _____ _ -----------------Foundation ____� ------------ Prop. Line _ ----- -----•- __ Length of each line_._____ �1 Total Length .___1�� ------------ LEACHING LINE [. No. of Lines �_, .�Z----- ---- - - p r, 'D' Box Type Filter Material _lid C -Depth Filter Material r ar ion ____ _ .____- Distance to newest: Well _.4--/------ FoundatProperty Line -- ------------ SEEPAGE PIT [ ] Depth ---------/�----- Diameter ---------------- Number --------------------------- !tock Filled Yes E] No H - Rock Size -------------------- Water Table Depth ---- ” -------------------------------- Distance-to nearest:-Well- `-- _�_"-=--- =--=-__:Foundation -------------------- Prop. me ----- ------------- I REPAIR/ADDITION(Prev. Sanitation Permit# -------------��,.�.-- � - -------ate -- __--_-------------------------) --------------------------- - Septic Tank (Specify Requirements) - - - , .-�,..��%�s a U jV -------- --------------------- Disposal Field (Specify Requirements) ----- ----- ----------------------------------- - - ------------- -------------------------------------j----------------------------------------------`------------------------ ------------------------ - - q � J {Draw existing and required addition on rev rse side) J. ,..._ I hereby certify that I have prepared-this application and.that.-the work.will be done in accordance"with:`gan Joaquin 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: Uj "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 bec 'ect to Work pen t' Taws of California." Signed Owner ------------------------ Title ----------- ------------------------------------------------ ----------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------_ -R-Q------------------- = - �------- ----------- DATE -----1�'Z _-.� -------------- _T.m =-- -- - ---- — - --- ---� =--�©A-TE---.'' _.._.__ " `------ BUILDING PERMIT-ISSUED ---- -- ------------—----------- - -----------=-:----DA ----------------------- -------------------------------------------------------------- .. ......... ADDITIONAL --- ------ ---------- ADDITIONAL COMMENTS _ �-T`-= =` ` -fat'��3�= ---_---- ------------ ---------- ----------- -------- ----------- ------- - =- ----------- ------------------ -- ---- - _ - ------------ --------- . ---------------- -- --- - -- ---- ------------- a l _ - Date Final SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H. 9 1-'b8 Rev. 5M