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.� FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Z- Permit No. -------- ---- --• --- -------------------------- -- -----• ""--""- ""--"- " (Complete in Triplicate ----- Date Issued _____ ---------- This Permit Expires 1'Year From Date Issued A Application ;s hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is maddlin compliance with County Ordinance No. 549 and existing Rules and Regulations: OB ADDRESS/LOCATION ----=----- - a CENSUS TRACT --------•------ • ! Jone ---------------•-------------• ---- Owner's Named -------------- Address ---- ----- �--+�--C1-7�--;--�----=--1•--p-��------�R_�'_ ----•-J�city . . - - -lv------- Licensehone — Contractor's Name R Installation will serve: esartment House Residence ❑ Ap ❑ Commercial ❑Trailer Court 0 Motel ❑Other Number of living units:------------ Number of bedrooms --------- --Garba.ge Grinder ------------ Lot Size -----------------------Private Wafter Supply: Public System and name __--_____________________ -_ ------------------ -- - •------ " Character of soil to a depth of 3 feet: Sand' Silt�CIay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material --------- if yes, type ---------------------------- N ize of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) U 4 0 {Plot plan, showings NEW INSTALLATION: (No septic tank or seeps a pit permitted if public sewer is available within 200 feet, V t 6 �J N ' _ X- --- Liquid Depth-W NEW TREATMENT [ SEPTI TANK'[�j� Size_______ _ -- I __ Material No. Compartments _ -- Capacity -Q 7Yp ' �K ♦ i A --- a- 'l I Pro Lin Distance to nearest: Well ___ ------- Foundation ZIP p Length of each line-�V------ Total Length ,_ IV—-------------•-- LEACHING LINE No. of lines ___ ---"-- -- j� 'D' Box _._ T e Filter Materia � r' Depth Filter Mafierial �_�------------=-----•---- •- yp Property Line Distande!to nearest: We ------ ---------------- ___ Diameter Number Rock Filled Yes ❑ No i❑ Depth ----------------------- - SEEPAGE PIT [ ] p �— iRock Size --------------------•-------•--- Water Table Depth ----------------- Distance'to nearest: Well -----r------------------------------------Foundation -------------------- Prop. Line ---------------------- <` ` ---- .-_. Date ------- -----------"---------- } REPAIR/ADDITION(Prev. Sanitation Permit�# ----------=- - ' ------ - -. --------------------------------------------------------- Septic Tank (Specify Requirements ----------------------------------------------- 7 ------ ----- -------------------=-------------- - - - - Disposal Field {Specify Requirements) ---------------------------------------- ----------------------------------------------------=----------------------- ---------- ------------- ----------------- -------------------------- ------ ------- ------------------------------------------------- i ;. ------------------------------------------------------ _ -------------------------- I. i (Draw existing and required addition on reverse side) ne in I hereby certify that ! have prepared this application h Son snd that the work will be of the San .Joaquin Local oHeal h District. Hom ce itowner or {cen- County Ordinances, State Laws; and Rules an sed agents signature certifies the following: for which this permit is issued, I shall not employ any person in such manner "! certify that in the performance of the work as to become subject to Workman's Compensation laws of California." Owner „�, Signed ----------- ----- ---- -------------------------------------------------- J R 1 .1 ------------ -------------- Sitle ! �' (lf other than owner] FOR DEPARTMENT USE ONLY i _ _ _ DATE =--�--��-��------------- ------ APPLICATION ACCEPTED BY -- � �'�------ ----- ---- - -------------�---------------- -----•- ------ -- DATE - ------ --------------------------------- BUILDING ----- ------- ------ ------ -- BUILDING PERMIT ISSUED ------ I--------------------- ------------ ADDITIONAL COMMENTS -------- ------------------------------------------------------- ---- -- - ----------------------- _ ---- -------- -------- -------- --------------;- - -- - ate ------ --- .z � 7z Final Inspection b "" SAN JOAQUIN CAL HEALTH DISTRICT r is 9 1268 Rev. 5M