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y FOR OFFICE USE: .1 APPLICATION FOR SANITATION PERMIT r Permit No. - _Z_-.3 {Complete in Triplicate] ---------=------- ------------------------------------- Date Issued ---------------------____ This Permit Expires 1 Year From 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 - 3 7 -161 fZ> _ -----------CENSUS TRACT "" . Owner's Name 1/"a --------- -------------------------------------- - - ..--Phone. , �u-%'------ / :" -r�c - Address ."--- ---- . / f l_�(?l-1_ ----------------------------------- City _7 _ "� 1-f� � --------------------------.-..---------- Contractar's NameLEIUcense # yI .-- Phone " F Installation will serve: Residence [5 Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other --------------------------------------------__"-_ � Number of living units:_"""""J_-." Number of bedrooms -_ "_""_Garboge Grinder ------------ Lot Size ".__""""_�""-_"_":_"_-""""""__.--"__"-- Water Supply. Public System and,hname ---------------------------------------------_----------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'X Silt E) Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam .[]. ' Hardpan ❑ Adobe ❑ Fill Material -AIP'--- If yes, type -------------------------- II (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) W NEW INSTALLATION: (No septic tank or seep pit permitted if public sewer is available within 200 feet,) o� PACKAGE TREATMENT [ ] SEPTIC TANK Size-""" -" y!' -- ---------- --- Liquid Depth """ ��' ------ c tj Capacity"_1 �-____ Type _ �'t.�' Material" aQ! o. Compartments -_-— .".".""...... Distance'11 to nearest: Well -----_ _4�_l-"-__Foundation ___/_0------------ Prop. Line ---�" ------..----- LEACHING LINE { No. of Lines --------3--_--------- Length of each,line------7 -------------- Total Length __j/p_---_- D' Box M___-.__"""" Type Filter Materialt"__.Depth Filter Material "_l- ""_"_"----------------------------- .I �v------I--- Property Line. --`�--f------- Distancei,``to nearest: Well _____�-"""_""_____ Foundation __._" ------- SEEPAGE PIT /]'Depth IE----------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes E] No Q WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance Ito nearest: Well _______-""""""""._-_"_-"_""_"_""..._--._Foundation --------------- ---- Prop. Line -•------------------ - REPAIR/ADDITION{Prev. Sanitation Permit# -------------------------------------------- itf Date ----------------------------- Septic Tank (Specify Requirements) ------------- --------------------- ----------------------------- ------------------•---------)- ------�--.-�--------- ------------------ DisposalField (Specify Requirements) ----------------------------------------------------------------------------------------------------------------- --------------- --------------------- =i -- ------------------------------------------------------------ -- ---- _ - _ - --------- - ---------- -------- ------------------------------------------------ ------------------------ ---------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) �- I 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, I shall not employ any person in such manner as to become subject to Workm n's Compensation laws of California." I Signed as -- ----- --------------------- Owner tBY - --�-- 1 r -- Title ------------ ---------------------------------------------------------- (If other than owner) ' FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- -.-�-------------------------------------------------------------- DATE ---------- ----------------- ------ BUILDING PERMIT ISSUED ----__I------------------------------------------------------- --------------------------------------DATE ' ------------------------------------------- ADDITIONALCOMMENTS --------- M- ---------------------------------------------------------------:-------------------------- -------------------------- --------------------------: --------- ---------------- ------------------- --------- -- ---------- ------------------------------ -------------- FinalInsP --- - P ------------ --------------------Date - ------------------------ SAN --- ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT . E. H. 9 1-'6$ Rev. 5M ;�