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FOR OFFICE USE: --------- --- APPLICATION FOR SANITATION PERMIT - 'Camp leFe in Triplicate) Permit No. ---------=----------------------------------------------- __________________ This Permit Expir4s�1 Year From Date Issued Date Issued _.�_ Application is hereby made to the San Joaquin Local H aItfi_District for a permit-tti-construct and install the work herein described. This application is made in compliance wltlt (°ounty Ordinance No. 549 and existing Rules and Regulations: 3 JOB ADDRESS/LOCA710 _____ - _____ ---- Via_ _ ___.____.________CENSUS TRACT ____ �._ .__._ Owner's Name ------ - -- � I /� .�} --------------------- ---------------=J-------------------Phone -----------------------------_....._ Address 1' ..7 1 p ��E- City �--1�----.�------------------- Contractor's Name ---- L_ L-> -i-1 ---------------License # ---------:-------------- Phone ----------------------------- Installation will serve: Residence partment House❑ Commercial ❑Trailer Court i❑ Motel ❑ Other -------------------------------------------- �t Number of living units:----- Number of bedrooms :�_3 ____Garba_ge Grinder _ ._ Lot Size _19CKFA-6_i�_____-__---. Water Supply: Public System and name --------------------------- `-------------------------- ----------'-----------------------------------Private �~ Character of soil t'� depth c�3 feet; Sand'❑ Si t❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 9__� x Hardpan Adobe E] Fill Material if yes,type ____________________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seep a pit'permitted if public sewer is available within 200 feet,) AO/ PACKAGE TREATMENT { ] SEPTI TANK _-Size-�'x_�Q_=R 5____ V`5;1 Liquid Depth __yD____________ J Capacity 12 Q 0--- Type hqF--C__AS7 Material_CP1VCR._7` No. Compartments ____�� Dis`farice to nearest; Well _____ ___ _`:__ ____Foundation Prop, Line __ LEACHING LINK s- No. of Lines ____ ___________ Length of each. line___._ ____.__.__ Total Length :._ S ___/_____.. 'D' SoxyF5_ Type Filter Materigi Aoc6__Depth Filter Material -------- � Distance to nearest: Well ----,$--- - Foundation _____ Property Line __ _ ...... r SEEPAGE PIT V Depth _ �� ___ (___/__.__ Diameter _rx_ � . Number ------�—_-------- Rock Fi ed Yes B No ❑ U Water Table Depth,___ �� -_ _ Rock Size Y _. Distance to nearest: Well ---_-��_ ____ _____________joynclation ----1.__--------- Prop. Line ----.�___________ � REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ------------------------------------ Septic ---_:---------------------------_Septic Tank (Specify Requirements) ----- ----- ------------------------------------------------------------------'---------------• ------------------------------------- Disposal Field (Specify Requirements) ---------- -----------------------------------------------------f------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------- ------------------------------------------------------------ ------------------------------------------ -----=-------------------------------------- --------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that the work will be done 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: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become'' subje t to orkm Compensation laws of California." Signed -------------------------------------------- Owner By ------------- -------------------------------------------'------------------------------- ------ Title -------- ------------- ------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------T_ ------------------------------------------------ - -- -- - --------- DATE ------A ---7710 , BUILDING PERMIT ISSUED---------------------------- - - --DATE --- _ ADDITIONAL COMMENTS -- i_: , :-----;- ------------------------------ -� –., 4.l �. °" �. \ ---------------- -------------------- - ---- --- --------- --------- ------- ----- ----- ------------------------------------------------------------ Final Inspec irn Date --- =-- -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M