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r FOR OFFICE USE:r r APPLICATION FOR SANITATION PERMIT Permit No. 6�_S7 o -- (Complete in Triplicate) --------------------------------------------------------- x _-------_----._---- This Permit Expires 7 Year From Date Issued Date Issued X-=s3!0::_6,.7 Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein describe. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: 1 f Z5^&F f t T . --CENSUS TRACTJOB ADDRESS/LOCAT ON --= - ------ � -- , M OwnersName w_/4 �� f 1r - ------------ ------ ---- ------- -------Phone. ��=------------------- 12 ------------------ f — _ I Address' f _ �" ----- ------- 'City _ t--------------------------- -- �p� 1 �' - - - Contractor's Name -Cieense-#`ra ===�Pl�one Installation will served '❑Residence [g partment HouseCommercial :❑Trailer Court ;❑ -------- -- -. Motel E]Other _ ------------------------- Num _______ -__ Number of living units:--- Garba` !' - -= "'- ---"" Number of bedrooms ___ _____--_ gee. Grinder . L�t:.Size-� Ir i Water Supply: Publi�Systern and name ------- ---------------- ----- I- ------ ------Private 0� i Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ feat❑ Sandy LoamC] Clay Loam ;❑ . Hardpan ❑ Adobe ❑j' Fill Mate al _txQ :. [f yes, type ------------ (Plot plan, showing size �f lot, location of system in relation to weld, buildings, etc. must be placed on reverse side.) y . i is NEW INSTALLATION: (No septic tank or seepage pit permuted if public sEyer Iii available within.200 feet,] PACKAGE TREATMENT [ SEPTIC TANK f,] S ze---- ----- ------------------- Liquid Depth ---------------------.-•.-- capacity ------- - -----0--YPe ------------- ------ Mate ialz---------?----------- No. Compartments .----- •--•---- Distance to nearest' Well -------------- --- --------1�s_�_Foundation ________________----- Prop. Line ---.------------_----- LEACHING LINE [ ] N01. of Lines ---------O•__{�----- Length of each fine---------------------------- Total Length __-_--_-__--_-.__-_-_-__•.- 1 l 'DT Box ------------ Type Filter Material _--_A- ------Depth Filter Material -------------------- 5 Distance to nearest: Well --------------_- ._,_ tindation ------------------ ---- Property Line ------------------------ --------------- ____________ -__._____ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ____._..__.____L___ -_._ Rock Filled Yes '❑ No i❑ Water Table bepth --------------- . ---------.._..._..Rock Size .�---- ----------------------- Distance to n�arest: Well ------------------------------------------ - Foundation -------------------- Prop. Line ---------------------- 4 REPAIR/ADDITION(Prev. Sanitation Parnit# _____-_..-- __________________________ Date ---------- ---------------------- Septic ________ ___.-------_Septic Tank (Specify Requirements) __-_-. '--- ---- ----- �'`-- ... : !." Disposal Field (S ecify Re gements) -- --------------�. .p`> -1 � -D1STA----13OX-------- ------------�-----------------------7. ---------- � cH N -------------------------------------------------------------------------------------------------------.---------------------------------------------------------------- _------------------------- `,. (Draw existing and required addition oh:reverse side) 1 hereby certify that I have prepared this application and that the wo.c�wili 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: I "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner I` as to become subject to W' rkman's Compensation laws of California." Signed ---- ---------------------------------- -! - Owner BY --- �� ---------- Title -------------- ----- -------------------------------------------------- (If 04 er thaFi owner) _ FOR DEPARTMENT USE ONLY q APPLICATION ACCEPTED BY --- F i = 0---------------------------------------- ---------------------- DATE ------ BUILDING ----BUILDING PERMIT ISSUED -------------------- --------------------------------------------------------------------------------DATE -------------•------------- --------------- ADDITIONAL COMMENTS ---- -- ------------------------------------------------------- ----------•---------------- ---------------------------------------- - -- ---------- -- ------------ - ------- ------- ---- -------------- -- ----- - ------------- ------------ ------ - - ------------ --- ---------- ------------ ------------------------------------ - -- --- ------------------------------------------------------------------------�--- Final Inspec ' --•------------ ---- - - --------.Date ---- ------- --3----�------------------------------------------------ --------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M