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FOR OFFICE U E: s,m APPLICATION FOR SANITATION PERMIT_2e.4 '5 r' 7a ------------ ------- Permit No. (Complete in Triplicate) ---------=----------------------------------------------- Date Issued ----------------------------_------------------ This Permit Expires 1 Year From Date Issued t 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 ��.-�-----�----��1 ��"�- ------------------;----------- - ----CENSUS TRACT ------------ �^ • ..------ Owner's Name �/1 -ie :-- r l�---------tea. -ejA_Po�----------------- -----------�------Phone - a7 l�"',. �C?.... Address _157_J-------. ------' �t ----------------------- City -=-A4- � i y . ,l�'y Contractor's Name, A��!-�t_ i�i '_ -ucllk�t_t� -- +-SS - QLicense # 1F1� �1--___ Phone �E�' _ �...- Installation will serve: Residence 2<`artment House'D Commercial :❑Trailer Court i❑ Motel ❑Other ---------------------- f - Number of living units.---/------ Number of bedroo s -----!-----Garbage`Grinde-r-- -------- Lot Size _AW12 k__��---------------•-•-- Water Supply: Public System and name -_GA44t4 >--_----_- '----------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Siltfl Clay ❑ Peat Sandy Loam ❑ Clay Loam:E] i Hardpan ❑ Adobe` Fill Material ------------ If yes, type ---------------------------- F (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,) V PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth -------------------------- Capacity -------------------- ------Ca acit Type -------------------- Material---------------------- No. Compartments -------------- - . Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ----- ----------------- ' LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length _----_.----.----_----.---- 'D'oBox------------- Type Filter Material ----------------- Depth Filter Material------------------------------------------- Distance ------------------------------•----•- Distance to nearest:�-Well -------------- ------- Foundation;:------------------------ Property Line --------_---_---.'--•-•-• SEEPAGE PIT [ ] i 'Depth -------------------- Dia`ter.,,,•-__-_--_0Number ------------------------------ Rock Filled Yes 0 No 0 Water Table Depth ---------------Rock Size -----=-- •--------------=--=--•--•----- i ' t Distance to nearest: Well --------------------- ------------......Foundation -- ----------------- Prop. Line .i-----__..__---_-_.. SI REPAIR/ADDITION(Prev. Sanitation Permit# -----------------------------_�------------- Date -------------- ------------------1 Septic Tank (Specify Requirements) --------------------------------- ------------; ------------------- � ,.. � -�.. ¢ r' ,� .-.,r_/ 0-1 .% 1i-...... 10";;w-----. K ----------- Disposal Field (Specify Requirements) �-� _,�-�---�-.--------�x�----- - - - ;,,. -------------------- --------------------- -- - ------------------------------------------------ ---------- - -- -- -------- -------------------------------------- -------------------- r (Draw existing and required addition on reverse sidejL--,.--------------- ,w.......,A 1-010, Ik I hereby certify that I have prepared this application and that the work will1be done in accordance with San Joaquin County Ordinances,.,State Laws, and Rules and Regulations of the San Joaquin'l.ocal Health Distract. Home owner or liven= sed agents signature certifies the following: "I certify that in theperformance of the work for which this permit is issued, I:shall not employ any person in such manner as to become subject`ci Workman's Compensation laws of California." Signed -�-� - Owner =----------------- `r BY s Title ----- �ZCtt� -- -------------------------------- `' [ f other than owner FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - • ----f- ------ - -- - -----=------------------------------- DATE-4-1- ----- BUILDING --BUILDING PERMIT ISSUED ------------------- ' - --- ---------- ----------DATE ---------------------1 ADDITIONAL COMMENTS ----------- "."" " .'.`"r.'"_--.'."�k�`T"'.. ��--�---------- ----- {---- --------------------------------------------------------------------------- ----------------- f _ - ----------------------------------- 7 ------ ------------------------------- ------- Final Inspection by: atel ^_j - JOAQUIN LOCAL---HEA-LTH---DI-STR-I-C-T r F E. H. 9 1-'b8 Rev. 5M