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FOR OFFICE USE, --------- ------ -nAPPLICATION FOR SANITATION PERMIT --- Z-_ (Complete in Triplicate) Permit No. ��/Q45/— ---------------- --- ------ ------ This Permit Expires 1 Year From Date issued ------------- - Date issued .4�- Application is hereby made to the San Joaquin Lac ealth District for a permit to construct and install the work herein described. This application is made in com fiance ith County O dinance 549 and existing Rules and Regulations: JOB ADDRESS/LOC 9LON fj CENSUS TRACT - wner's Name - ---- "� � - -- --- ------ -- - -------- - ------ -- -- - --- ------------------------- ---.Phan Address ---- ----- --------- -------------- Contractor's ------ ----- City ----------------------------•- ---------------------------- Contractor's Name -. � _-._-.--_.__ r - ------.License # ----------------------- Phone Installation will serve: Residence Apartment House'❑ Commercial:❑Trailer Court i❑ ------------- Motel ❑ Other __--__- Number of living units;--./---_- Number of ooms,3--------Gar a Gri er : ------- -- Lot Size _ ,QQ -bC.�- -(.-.---_---- Water Supply: Public System and name _-___--_ : --- Character of soil to a depth of 3 feet: Sand' --� -----� ---------------Private ElS ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam [7] Hardpan ❑ Adobe 5( Fill Material ------------ If yes, t (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 permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT �-- N [ � SEPTIC TANK:[ ] �� Size---------------= Capacity ----- ----- •-- Type -------' -------- --- � ------------------ Liquid Depth -------------------- Distance to nearest: Well ----------------------------- -_ _- - . -- LEACHING LINE' q ------ Material---------------------- No. Compartments --------------------_--___- ------------------Foundation ---------------------- Prop. Line ----------- ----•----- [ ] No. of Lines ---------------------- Length of each line---------------------------- Total Length Box --------------Type"Filter Material --------------------Depth Filter Material ----------_ -- ------------------------------ Distanee to nearest: Well ---------- ----- --- - Foundation ------------------------ Property Line. SEEPAGE PIT dr ' -------------------••-_- , [ ] Depth -------------------- Diameter Number --------- ------ Rock Filled Yes E] No i❑ 1 Water Table Depth ------------------------- ----Rock Size --- Distance to nearest: Well --_---_-------- --_ _Foundation ------------------ --- Prop. Line -..------------------- - ----------------- REPAIR/ADDITION(Prey.Sanitation Permit# -------------------------------------------- Date -- ----------------- --- -- Septic Tank (Specify Requirements) ---------------- ' ---------------------` ---------:-------- - Disposal Field (Specify Requirements) ----------�_ a° ----- ------- ---- - ----------- -- ---- ' f ----------- ---�a.� - --------------------- ------------- -- _ (Draw existing and required addition on rev se side) I hereby certify that I have prepared this application and that the work will be accordance with San e i donn Joaquin , County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or iicen- sed agents signature certifies the following: "I certify that in the performance of the work f which this permit is issued, I shall not employ any person in such manner as to becom subject o Work an's Co pe ati lifornia." Signed -- -0 BY _ --- - -- ----- - -�...... Owner ----- -r-- ------ Title -------- ----------other than owner) FOR .DEPARTMENT. USE ONLY K- APPLICATION ACCEPTED BY --- ---------------------- - DDITBUILDING PERMIT ISSUED -. ------,--- ----- ----- -- ----- ------ ------ -------DATE ADDITIONAL COMMENTS ._��-/�'-��_-_�_ f - - �� - ----- ---•---- ------- ----- � -ETr' _. - ------------ - -------- ---------- --- � �` - rx" 'z`' 1 -------r— '- ---- --------------------------------------------------- ------------------------------------------- ------------- -------------- ------- -------- ----------------- ---------------------------- -- Final inspection by: -------------- _ _ -- ---- ------------------------------------------- ------- Date -----�� SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 7-'b8 Rev. 5M,