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' FOR OFF+_E USE: APPLICATION FOR SANITATION PERMIT ---- --------------- ---------- rNi-A_4 (Complete in Triplicate) Permit No: ��- ...... --- -_____-_________ This Permit Expires'l Year From Date issued Date Issued �� /_-- 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 in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ----- 0go _- j '---�------��1I�A 4 ---- R�✓---- ------------ - -------CENSUS TRACT Owner's Name ---------- = C !'"� e�._4 e-)- - ---------------------------------=------------------------------------Phone --------------- Address --- ----------- s3 dY -------------------- Y �,_ -----. City --------- ----------------- ---- Contractor's Name ------�___ N_7'/)__taNr- --J�oW----------------------------License #A "� --- Phone�__�_3 " I`�l ! ------- --- Installation will serve: Residence [YApartment House❑ Commercial :❑Trailer Court ;❑ Motel ❑Other Number of living units--------/-. Number of bedrooms _-7------Garba-ge Grinder _N�---- Lot Size __ _ __ ------------------------ Water Supply: Public System and name _______________________________ Private t Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ® Clay Loam ❑ Hardpan ❑ Adobe-❑ Fill Material _ ---------- If yes, type ---------------------------- (Plot ------_--------------_(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 seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT f ] SEPTIC TANK f Size------�� .-qs_��1�-------- Liquid Depth ____-- -.~---- W i '2oo 0 Capacity -------------------- Type /�Y'C �e4S�Material- _C_d HC'--- No. Compartments _' .......... Distance to nearest: Well ____-___S-O--'- ----- -- _ __ _.-Foundation ---- - �______-_ Prop. Line -__-�'0 LEACHING -- - - 4 LEACHING LINE LK No. of Lines -------3 Length of each line_______d'a r_- -_____ Total Length --- _ye ----------------- 'D' Box ---/------ Type Filter Material � ___-Depth Filter Material ___-_�_0 ' Distance to nearest: Well ______-_0_'______--- Foundation -.__�-�^_r_______ Property Line -'� SEEPAGE PIT [ ] Depth __---_--_______-__ Diameter ____________ ___ Number ---------------------------- Rock Filled Yes ❑ No i❑ —�� Water Table Depth ------------------------------------------------Rock Size . Distance to nearest: Well _________________________ ----•-•-------Foundation -------------------- Prop. Line ----------- •---- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------•-___-_- _--_-- Septic Tank (Specify Requirements) --------------------------------------- Disposal Field (Specify Requirements) ------------------------------------------------ E ------------------ - --- ------- -----------------------------------------------=----------------------------------------- ----------------------- (Draw existing and required addition on reverse side) Q 1 hereby certify that I 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: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ------- .--/9/1'-T/�oxv ��o Owner ---------------- By -- ------ = -' --------- ;title --- . (If other than owls ------- FOR DEPARTMENT SE ONLY APPLICATION ACCEPTED BY __-------------------------------------------- . _. -I2L BUILDING PERMIT ISSUED __________ ......... DATE ---------------•---- _____________ DATE ADDITIONAL COMMENTS --------------- - -------------------------------------------- -------------------------------- ------------------------- Final Inspection b -_ -- -------- - -- Y° _ -------- - -- ------ -Date - ---✓!�✓7� SAN JOAQUIN LOCAL HE=ALTH TRICT E. H. 9 1-'6B Rev. 5M