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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. . ................................................ (Complete in Triplicate) ..... ............................................. P Date Issued ......................... This Permit Ex ires 1 Yeor From Dote lssied 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 incompliancewits unty Ordinance No. 549 and existing Rules and 1. Regulations- ........ egulations:... ! .._.�./• ' ...t.... y .../i, [........_............_....CENSUS TRACT .......................... JOB ADDRESS/LOCATIO _ ` ��---O - - - __......... Phone .......... ...... Owner's Name ..... .... .. ...... .....- n Address ...._: l yll ...:. D ......`.City ... il........................ ` Contractor's Name ��' -s.�-- .. __� "`�'" Jd!f.P'......_..0.License #-41_18.�� -Phone .................... ...�.. installation will serve: Residence Apartment Mousefl Cornmerciai Ofrailer Court ' Motel ❑Other .......................................... Number of living units,.......... Number of bedrooms ..3..... Grinder ............ Lot Size .. ''t •••- __...............Privater Water Supply: Public System and name ................ 1 Character of soil to a depth of 3 feet: Sand 0 Silt[3Oily Peat❑ Sandy Loom O . Clay Loam ❑ Hardpan❑ Adobe 0 Fill Material ..:.........if yes,type ............................. (Plot pian, showing size of lot, location of system in relation to welts, buildings, etc. must be placed on revere side.) NEW INSTALLATION: (No septic tank or see ge pit permitted if pu lle sewer is available within 204 feet,) � i - PACKAGE TREATMENT [ ] SEPTIC TANK Size.._ ,rZ.-._-�--- � - Liquid Depth .._�.................. Capacity �.��'�..... Typee/ ''... Materiat.. �•— No: Compartments ..Z•:........... p ty •. � 11 ' -_. Prop. Line ..._.............._ Distance to nearest: Well _ . .40P --••-•-•-•--•••--••Foundation ..__I-�• � ./ Length of each line.......��. --.--_--. Total Length ._��.................•� 1 'EACHING LINE [7 No. of Lines -.-•---•�--•-- _De Depth Filtei:Materia! ....1f...................•....... _O 'D' Box - ----- Type Filter Material •...1J`•-- P .• / i / Line ....r-'•................. Distance to nearest, Well ....... -0.--_--••-••- Foundation .•_..�OP_--•••• Property [,� Depth _� Diameter . `.•._ Number ....... ---•- --.._ Rock Filled Yes [ No Q 01 SEEPAGE PIT P �i�� i /d� ,C .._j....Rock Size - ..... .... ....... Water Table Depth i ; ' Foundation .,�Q............. Prop. Line .._.__..._........_ .,1 Distance to nearest: Well l � ......... Q REPAIR/ADDITION(Prey. Sanitation Permit# ..........................................`.. Dote ................------ "- ......._... ................ Y Septic Tank (Specify Requirements) ......... .................................. - .... -.................................. Disposal Field (Specify Requirements) .• i/ vr ........ ...................... .... .~~..................... ......:................ (Draw existing and required addition on reverse si ce with Son Jooquln I hereby certify that I have prepared this applicationati d thilof the Sanoloaguin Local done, the wrk will be Hoc in County Ordinances, State Laws, alth District.Homo owner or lllcen' nd Riles and Reg ,, sed agents signature certifies the following: person In such mannas "t certify that in the performance of the work for which this permit is Issued. 1 she{{ not employ any as to become subject to Work�'mpensation iof Califomla." Signed ....._.. Ow .................................................. By ........................................ _... .__ • -.-, (tie - - If other than owner) FOR DEPARTMENT USE ONLY r --- •N- I�1-�. 1-�1t (f+-�•-_f -_-I!__, ......_........................... .. DATE ...3__t•17 - ....... DATE _ APPLICATION ACCEPTED BY •- BUILDING PERMIT ISSUED ______________ __..____-_-_-_______-_-- ---------------_-----_--•--..__.....__:............._..__.. , .. ....... ----_.~.-..---.-...... ADDITIONAL COMMENTS .............. .. ................... ......•••--- ....__......:..._...._.... - ...... - .... .......... ........................................ ... •.-. ..:.......... . -- -1111---1 ::....: - ._.....:.... _..._......._.. ..__:........•.•.._._..............Dase- e ;;.. '-`.:.7. ...............:.•. ......................_-----..-......_. ............. . - Final Inspection by. .... .......... _. SAN JOAQUIN -LOCAL HEALTH DISTRICT 7j723M .. 71 241 'AD Va 5M