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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FPermit No.. (Complete in Triplicate) I --- -- --I-------------------------------------- - Date Issued'5_—_:?-_-2 This Permit Expires 1 Year From Date Issued 74�-): 007-- OL/0--(O Application is hereby made to the San Joaquin Local Health District for a permit to konstruct and install the work herein described. This application is made.in compliance with County Ordinance No. 519 and exis��s and Regulations: " �p JOB ADDRESS/LOC TI N s------------{` ----fi"- --- ----------------• "f -CENSUS TRACT Owner's Name -------- ------------------------------- ----- on = P e Address a" .fir- _ itY -•- Contractor's Name ±"- -z-.�'--- --- ------------ I' ----- ---hicense # !_ p Y--- Phone ---------------------•------- Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ❑ Motel ❑Other ---,-- -"--------------- •------------------ Number of living units:------ Number of bedrooms --___Garbage Grinder - _______ Lot Size .._________________ ___ _ _.._ --------- Water Supply: Public�System and name -------------------------------•--------------- ------------ -----•------------------------------ Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -0 Clay Loam Hardpan ❑ Adobe '❑ Fill Material ------------ 1f 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 Y SEPTIC TANK[ ] Size_° '" '_ =� u s - Liquid Depth ____------------_------ Capacity -lz-fid-_ 4ype61-4-CAF-j9A.4A_ -- MaterialNo. Compartments - ........ _ U Distance to Weare Well _______-1� r-----------------Foundation __._:fid_-......... Prop. Line LEACHING LINE No. of Lines ---------j------------- Length of each line---SO_r--------_----- Total Length _______-:--. -- 5_ 'D' Box .'_ Type Filter Material '______Depth Filter Material ---I7------------------------------------ C ! l Distance o nearest: Well --+�____________ ____ Foundation _____.____l-a_______-- Property Line �"_.____....___...:..-- i -___ Number ---------�____._.________ Rock Filled Yes � No C] SEEPAGE PIT `� ] Depth _.__- f__ ___ Diameter ___3___ it Water Table Depth --------------F8-----------------------------Rock Size X- -r'------------- Distance to nearest: Well -------.__1Q P--r-----------------Foundation ------/_V__1----- Prop. Line __.9--_------.--..- REP DITION ev. Sanitation Permit# -------- ----------------------------------- Date ----------------------------------) Septic (Specify Requirements) ----------------------------------------------------------- -----------------------------=--------------------•- --------------------------- DisposalField (Specify Requirements) ------ ------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------- ---------------- ---------------------------------- ------------------------------------------ --------------------------------------------------------------------------- (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: "F 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 Workman's Compensation laws of California." Signed -- --------------- �j - ---------------------------------- Owner B �*J_, - Title . -- ------ Y -------------------- (If other than ow er) / FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----. -- -- - --- - ------------------------------------------------------------ DATE ----------------- BUILDINGPERMIT ISSUED ------------------------------------------------------------ ----------------------------- --------------DATE ------------------------------------------ ADDITIONALCOMMENTS ------------------------------------------------------------------------- ----------------- ----------------------------------L------------------- ----------- _ _ _ _ __ _________ ________ Final Inspection by: _ Date: ©_-. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M