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r FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ' /�/ ,,av ,1. w Permit No,. 'fes i (Complete in Triplicate) -- _ M� Date Issued 7Z AThis Permit l;xpires 1;,Year From Date Issued ----------- - 1 a �y n F j r �i r Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the•wofkNerein I . described. This application is and a in compliance with County Ordinance No-549 and existing Rules and Regula ns: [ ` o .i.. .. .4. .-, - � I ` ,r ,,� _- �Wai�-----------.CENSUS TRACTa-V4e A— JOB ADDRESS/LOCATION . /� � Owner's Name R�-a y"� --- - f'd �'�;` - T�C, I I C'S ----------Phone -------- --------------------------- Address �cL2 '� 4` �t '�----------------------------- City '°G 7�aa, -----------------------------------'-------- I. Contractor's Name-77z4--' -- - ,. 1 -- i.License # �---- Phone -------------- .-- = Q • .-t -- Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court l❑ Number of living units:___/-_ -- Number of bedrooms - -__Garbo a Gnnd � `� t Mote ❑ Other ------------------------------- g 4 eer ----------- Lot�Size - -- ---------- --/----------------- Water Supply: Public System and name ------ _ - � '-------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'0 ilt ❑ Gay ❑ Peat❑ Sandy Loam '❑ Clay Loam ❑ Hardpan ❑ Adobe P< 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 seepage pit permitted if public sewer is available within 200 feet,[ PACKAGE TREATMENT [ ] SEPTIC TANK 9- Size_____ _ Liquid Depth --- ------------ ` Capacity die? Type >p �� _ Material_01-pra ---- No. Compartments .--- ---- 1� Distance to nearest: Well ----------Foundation ---------- Prop. Line ----- ----:__._..-- F ~ # LEACHING LINE No. of Lines -----Z---------------- Length of each line-__,7_J--------------- Total Length --------- � 'D' Box ____ Type Filter Material S14 �- --Depth - �- -- -Filter Material sP--------------------- Distance - -Distance to nearest: Well -14_v__rhC------- Foundation -------1.t9--------- Property Line ---------- . SEEPAGE PIT fkZ Depth -------- Diameter _ ._s3 __ Number ------- ------Ro"s`F i Yes No .0 / -------------------------------- --- �► Water Table Depth ----CC�_fQ---- Rock Size ---�--�---- - ,i Distance to nearest: Well __ 4'7+A�-----------------Founds _._.. Prop. Line -----.---------------. REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ------------------= -------- ------------------------------------- ---- _----------------- DisposalField (Specify Requirements) ------------------------------ ------------------------------------------------------------------------------------------ ----------- i -------------------------------------------------------------------------------------------- ------------------------- --- ------------------ ----- ---------------------------------------------------------------------------------------------------------------------------------------------- i (Draw existing and required addition on reverse side) i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin i, 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, I shall not employ any person in such manner as to bec s bj rt to Wo kman' Co ensati.o of Ca 'fornia." Signec��-�---�- -1C �'C "� � ��"�� `fir 4 1 iBY ----- ----------------------- + ----------- Title ----------------------- --------------------- ------------------ (If other than owner) FOR DEPARTMENT USE ONLY ---------------- rr� APPLICATION ACCEPTED BY ------------- --1/47------ - ------- DATE ..... BUILDING PERMIT ISSUED _ ._ -------------DATE ------------------ ---------------------- - ADDITIONAL COMMENTS -ix- 6 ' ---- --------- r -------------- ---------------------------------------------------------- i ---------------------------- ---------------- -------- -- Final Inspection by: ------------- ---------------------- -------------------------------------------------------------.- -----.Date ---._ _G - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M