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Ft2R Or-HCE USE: APPLICATION FOR SANITATION PERMIT c� - --- -- - --------------------------------------------- Permit No: (Complete in Triplicate) t - This Permit Expires 1 Year From Date Issued Date Issued ______ Application is hereby made to the San Joaquin Local Wealth District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 5.49 and existing Rules and Regulations. . JOB ADDRESS/LOCATION ._ -- _ l V '-- ----CENSUS TRACT -- L�-^ Owner's Name _ - ------ -- � --- - �--------------------- ' -- ---------��.��- - ---------- �•- - '�-�-�+---'------ --� ,� Phone --- ----------=------------------- I�_Q 3_ � �----------- Address - -`-®--- -X-------- - ----------------- city ��-�.00� ------ ------------------------------------------- Contractor's Contractor's Name ----- --------s---------------------- ------------ ---License..#J---...... Phone ------------------------------ Installation will serve: Residence VApartment House-D Commercialt❑Trdiler Court ❑ in Motel❑ Other -------------- --------- ---------------- -4 Number of living . ___units:_ Num�ber`of bedrooms 3, ----- Grinde/.�— Lot Size -- - Water Supply: Public System and name ---------------------------------------------------------------------------•---- ----------------------------Private Character of soil top.delsth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat Sandy Loam )ZClay Loam.❑ . Hardpan ') Adobe ❑ Fill Ma .terial _ �__�If yes, type _____ _ __________________ g (Plot plan, showing,size of lot, location,of�system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: fNo septic tank or seepage pit peer imtted if public sewer is available within 200 feet,) Q PACKAGE TREATMENT [ SEPTIC TANK' .Size--- Liquid Depth -------- - } Capacity �3_.Q�___ Type EFt9B Material CO No. Compartments _____ .... ig Distance to nearest. Well -----``---Foundation ___/__ 77? p �` r _~ f ' � ----------- -� --- Prop. ------`-�---•--•--••- Len Length of each line,.____.;._ LEACHING LINE:.-. No. of Lines __-___2L_._ g ! -�__.._..__ Total Length .... 'D' Box"�� Type Filter Material �l,_O�tN_.Depth�Filter4Material -------- _-1------------------------------ I Distance to nearest: Well _--- --,-�_-, Fotndation ------------------------ Property Line ___�----_�--___ SEEPAGE PITS Dept _.____- Diameter;lt`�1t� Number ':." Sf.r_ _F_* Rock Filled Yes;�'� No 0 , Water able Depth __ -__----------------------------...Rock S 2 Foundation _- __ _--- Pro Line ....-�_- Distance to,nearest.-We e ------ ---------------- -_---- p REPAIR/ADDITION(Prev. Sanitation Permit# --------.------------__-----------------__ -Date __________________________-------)_-.:.,,..,.,,, SepticTank (Specify Requirements) ------------------------------------------------------------------------------- --=------------------•--------,..--------------------------- i DisposalField (Specify Requirements) ---------------------------------------•-------------------------------=----------------------'-------------------------------------- { (Draw existing and required addition on reverse side) I Thereby certify that I have prepared .this application and that the work twill ibe�ldone� in accordance with San 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: ± "I certify t in`fhe performance a the work #or ich this rmit is issued, I shall not employ any person in such manner as to be ubject to Workma ompensati. I ws lifornia." Signed �� ".a.� - - ----- - Owner BY --------------------------- ' PRO. Title ------------------- - (If other than owner) t FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY ------ -r-7-13,�42----------------------------------------------------- ----- DATE __. *._ ---------- } BUILDING PERMIT-ISSUED. - ---------------------------- ------------------------------------------- •----,----- : DATE ,_.,__,.�,--. : ------------ - ADDITIONALCOMMENTS -- --- - ------=---------------------- = -------------------------- ---------u%-----------------------------=------------=-------------- ---------------------------------------- - -----�� ------------ _--------------------------------------------------------------- ----------- m. r _ --------------------- -------- - ---- -- ------------ -------------- -------- -- --- ----- ----------------------------------- - Final InspetHon--lay• --------- -- ---- Dated r . SAN JOAQUIN LOCAL WEALTH DISTRICT ' . E. H. 9 ` 1-'6B Rev. 5M 1