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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------ ------------------------------ - ------------------------------------------- (Complete in Triplicate) Permit No. --------------- This Permit Expires 1 Year from Date Issued Date Issued .-I'_�._-_:-�-v Application is hereby made to the San Joaquin Local Health District for ❑ 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: f .JOB ADDRESS/LOCATIONy�_:"J--- •Z2--CJ� IO � .--------- ---.--CENSUS TRACT -- Owner's Name - QL -/- - -- ------------ ------------------- one .CU 3^ = j Address f.�� - _I� C/V----?e ---------------------- City ------------ Contractor's Name _.__ ---.License #oR- - Phone IF IL Y--_ _ ? 1=------- 14 - - i-----' Installation will serve. Residence rf Apartment House[] Commercial ❑Trailer Court i❑ Motel ❑Other Number of living units:___._-�---- Number off"bedrooms ___-- Garbage Grinder --_-_--_.__ Lot Size _190a-ell ___________ n I - Water Supply: Public System and name -------------------- •-- ----------- ---------------------------------------Private Character of soil to a depth of 3 feet: Sand'- Silt❑ Clay_❑ Peat 0Sandy Loam ❑. Clay Loam 0 Hardpan ❑ Adobe'❑ Fill Material V__ 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 permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK;[ Size__---_____ .___�,1s--_, �-______ Liquid Depth _A4 U q p -----------•--•- Capacity ------ TypeMaterialA-,_-t0 - _ _ No. Compartments __----.�`i_-_-_-.__ c f � istance to nearest: Well -------- -------------------Foundation -------1-4-1 Prop. Line ----�-_.---------__ LEACHING LINE [ No, of Lines -- ' �- ------------ Length of each fine--- .7A.---- -------- Tota! Length --�-��--a------•- ------ 'D' Box -- -------- Type Filter Material ��L �r t -- -- - -----------Depth Filter Material ---f�------- ----------•-------•------ Distance to nearest: Well ------ �---------_ Foundation _ ---®_ -__ -� i � --- -- Property Line, --�_----=_--'----•-- SEEPAGE PIT [ ] Depth ---- -------------- Diameter - Number ------------- ---------- --- ----------- Rock Filled Yes ❑ No .0 i Water Table Depth ------------------------------------------------Rock Size ------------------------ Distance to.nearest: Well --------------------------- ---------•--Foundation -------------------- Prop. Line ------------------- i ... REPAIR/ADDITION(Prev. Sanitation 1 Permit# ----------------------------------- ------- Date ---------------------------------- Y>y a Septic Tank (Specify Requirements) --=---------------------- ------------------- -------------------- --- Disposal Field. (Specify Requirements) ______________________ _ _ _ -------- ----------------------------------------------------- ------------------------------------- ---------------- ------------------ ------------------- - --------------------------------------- - _ I(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: "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 t Workma 's Compensation laws of California." i Signed ------ -- Owner BY ------------ • Title -- ---------------- - - (If'other than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- s_ `�_© DATE -___��""� -_` BUILDING PERMIT ISSUED --------- DATE ADDITIONAL COMMENT --------------------------------•------------- -------------------- ---- ------ - - - - - - -- ------------------------------------------------------------------------ ---------------- Final Inspec i - --- -------------------------- / ---- -------------Date'-- --- -- ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT a c E. H. 9 1-'b8 Rev. 5M