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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT lComplete in Triplicate) Permit No. .... .-._ .w......� �, . _ ............----•-• -------- This Permit Expires 1 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 .............. .25. E. Dudley Rnaa ._......•.. .......... ...........CENSUS TRACT Owner's Name E. Agesen .... ...................... .... Phone ..................................... ..._....._.......................••. $25 E. budley Raad Address ....:........ •.. .. ._..... ..........,..................•-•••-:............. City ... ............. ......._......_..............._ Contractor's Name Roto Rooter Sewer Service Phone license # 271539 x+65-2616 ............... Installation will serve: Residence[N Apartment House f] Commercial❑Trailer Court ❑ Motel ❑Other............. ................. Number of diving units__!...... Number of bedrooms ...3.......Garbage Grinder ............ Lot Size ...5.-acre- Water Supply: Public System: and name ...._..__.. Private® ' ................. •--•-...................... ...................... Character of soil to a depth of 3 feet: Sand b Silt.[:] Clay ❑ Peat 0 Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe In Fill Material ............If yes,type ............... ............ (Plot plan, showing size of lot, location of system in relation to wells, buildings, b ! 9 � etc. must e paced on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size.........:.................. _...... Liquid Depth : Capacity -------------------- Type ----------•----_-- Material...................... No. Compartments Distance. to nearest: Well ---------............................Foundation ................ Prop. Line LEACHING LINE [ J No. of Cines'-..--------------------- length of each line.---- ._....._._-_- Total Length . ............. 'D' Box .._....__... Type Filter Material -- ..............Depth .filter Material ............................................ • Distance to nearest: Well ........................ Foundation ................•................ Property Line ........................ SEEPAGE PIT Depth Diameter ___... Number ............................ Rock filled` Yes ] No [ 1 Water Table Depth ---------------------------------...............Rock Size ------.._..... ---••-••--........ Distance to nearest: Well -_._-................................:..Foundati .......•.on :.---.... Prop. Line _..... ............... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ..................................) ' Septic Tank (Specify Req uirementsj ............. add nev-sump ............................... .......... Disposal Field (Specify Requirements) Sump apex. 4' x 8' x 1Q' + -----•-•--------•__ - -r_--__••-•-•_-______--_-«--•--_•_•----------------- . ___.._________________----------------_______________________---- L _____________«._.____________.......__...__..___....................................--................................................... (Draw existing and required addition-on-reverse-side)- lhereby certify that f 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 Son 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 nat employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ---•----- -- •--- Owner - .--- By --------- t ` - - -------------------- Side C ----------------- y .----....--••-•--•- If of r than owned , t FOR DEPARTMENT WIEOLY { APPLI TION ACCEPTED BY .......______ __________ ____ - BUILDING PERMIT ISSUED ..._...__._ " ._ --...DATE .�/aI-IY.,.. ....... ...: --------------------- - !..------------ .- - ---------•--- ---DATE _ ------------•-•---....---.-.._..----- ADDITIONAL COMMENTS .--------..-•....................._. ------. --------- -------------------------`.........--•-----._-_-._...---•----.--..-------...----------_....----------••------_--•- •----- ...... Final Inspection by: ................----------••- ....... ..... . Date ..//:�`7�- . r--- c.: EH 13 21� 1-6t3 3Zev. SAN JOAQUIN LOCAL HEALTH DI RICT $�7� 3M