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FOR OFFICE USE: APPLICATION FOR SANITATION ;PERMIT (Complete in Triplicate) Permit This Permit Expires ] Year Fromtate Issued Date Issued -//�� 5`. 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 est Ug Rules and Regulations: J B ADDRESS/LOCATION .... �.......�I/GS•/ � I - �iJ ` 2�D�ocf ['y . �� CENSUS TRACT 4� Owner's Name �� ......Phoney.,3.._.. ...... Address ......... fp..3. .d......w..... ................ Crit Contractor's Name ......... "` _�!`.- !� /.-�. .� ��--- --------------------.-------------...lrcense #_��i "-5.-5��---- Phone: -s'�:�f��..... ' Installation will serve: Residence []Apartment House 0 CommJial [:]Trailer Court C] Motel ❑ Other ....�0.D ,4 .� �- Number of living units:.../._..... Number of bedrooms ...........:Garbo a Grinder ... -------- Lot Size ..... Water Supply: Public System and name ................. Private : ............. .................................. Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay 0 Peat! Sand Loam Clay Loam ❑ Hardpan ❑ Adobe P Fill Materiall ---- If yes,type ....................... .... (Plot plan, showing size of lot, location of system in relation to wells, guildings, etc. must be placed on reverse slde.I . Jr NEW INSTALLATION: (No septic tank or seepage pit ermitted if public Ilsewer is available within 200 feet,) .` 4 k °PACKAGE TREATMENT [ ] SEPTIC TANK-[ Size-----------------• -------- --�........... . Liquid Depth ....................... . ] � --- -- Capacity .. ... Type ..... .............. Materials... ' -- •--•--. N . Compartments .......•--............J+- Distance to nearest: Well _ .............................Foundation ......._ ........-.-.- Prop. Line --------------.__. __ LEACHING-LINE` [ I'—No.-6f Lines' . __ y .._ .. .. :.-. L gth of each line: ......... .�•..:...::....: Total. len th a D' Box Type Filter Ma erial --- epth Filter M erial. ............... Distance to nearest. Well -------- =._;.Y.. Foundat! n ._......... . _ -.-- ...._ Property Line ...------.... ........ SEEPAGE PIT [ j Depth Diameter ...... Number _ Rock Filled Yes ❑ No Water Table Depth --------------- ------......Rock Size ...... ----------- Distance ---- ---. Distance to nearest: Well .._...._ ..............Foundation _.-------- ----- Prop. Line ... REPAIR/ADDITION(Prev. Sanitation Permit# .......... ... ... ....... ...... D aItei.'.`..... :----.-------- ------------- Septic eiffegEe ) _------------- ............................. ...... ---- jip Disposal Field Requiemencs) . ............. iFP.L/ [- _ . X ..... E4 .. � :�1�—�SICAI- .. :-�OpCT MEM,3ZSij ....QN.L. (Draw existing and required' er addition on revse side) I hereby certify that i have prepared this application and twat the workiwill be done in accordance with San Joaquin County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or liven- 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 vs Cam snaatIon laws of California." Signed .._. .... � ,7n , .:.. Owner BY _... _. . .. --�.... ....... . . .............. •. - Title ...I (If other than owner) f FOR DEPARTMENT'.USE ONhi I .. .... .. r_'DATE �� .... ...... --- �— TE APPLICATION ACCEPTED BY ,-... _ l BUILDING;PERMIT ISSUED --- 'A _. ADDITIONAL COMMENTS ......._-•-- �.. ...... . --- •.............. ..... .... ... .... .... < i ------------------ ----•.....:... .... ---- ----- ... ' ' h s.. \. k Final Inspection = - Date ~. h _ -- -- SAN JOAQUIN LOCAL HEALTH DSTRICT c Li 13 24