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' FOR OFFICE USE: ....... ...... ....... APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. . ...... ` Date Issued ...................................................I!._-.• This Permit Expires 1 Year From_bate Issued -- Application is hereby mode to the San Joaquin Local Health District for a perm to construct and install the work herein described. This application �s made in compliance with County Ordinance No. 549 and existing Rules and Regulations: �I; ,,cc�� Ir I JOB ADDRESS/LOCATIONiT.....`V. TO...... -` •. _.......CENSUS TRACT ---------------- ......... Owner's Name ............ " ---- ----- - ------.Phone f t q. .3X .-...... . Address .. ..-..... .. ��-1. � .,, trt . . - ._ :... City 1 - Contractor's Name .. -µ -.--..rYC/� ._.._..:_.License #A�:`.3�}'3._. phone ..-...-6'��_.-_ I rx installation will serve Residence 'A _grtmernt,House 1❑.,Commereial OTrailw.Court ❑ r / !M-65Q n Other . ..:._----------------- ....... ..... Number of living units:.... , Number of bedrooms 3......Garbdg,.Grinder �oti.zeC ..................... Water Supply. Public Syem and name - r _...... -------Private C] Character of soil to a depth�of 3-feet: Sand Silt❑ Clay ❑ Peat'El Sandy Loam Gay Loam I : �I Hardpan ❑ Adobe ❑ Fill Material ........:_.. 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: (Nb septic tank or seepage pit permitted if.public sewer is-available within 200 feet,} r F PACKAGE TREATMENT ( �� SEPTIC TANK Size--------�--.- .!.�....................... Liquid Depth ...... J 1 2� Calpacity Type 1�c. ....... Material... _1� .;=.. yNo. Compartments ... A Of Distance to nearest: Well ................ ,� .._..... Prop. Line ... ._..... LEACHING LINE N]II. of Lines Length of each line).AL. Total Length ..I Q.. ............. 'D' Box . .. � Type Filter Material p� �. rp t � t ' N .. ..!'�`--'_-- De th Filter Material ....../8.................... ..•--..... } Distance to nearest: Well ........................ Foundat on _ l'. t.-1. Property Line ._.>—.,I-_........... SEEPAGE PIT Depth _-.-_ Diameter q_ _ ..... Number .......r ..._.:s...._ Rock Filled Yes No C) Water—Table-Depth _-.--.=-..•---_-_Rock Si -•--------- / I . 'Distance to nearest: Well ........................•-------•------1Fouradat:ior _ t'... Prop. Line._-_�.......... REPAIR/ADDITION(Pre) Sanitation Permit# ....................... Date ........................... .._..) r q Septic Tank (Specify Requirements} ..............-•---------------- ---------------.......-----............I....... ......-. ......._........ Disposal Field (Specify Requirements) ...........................-N---,--..-----....------------------ - • -......_...-..... ......._..------ a-_.. ...- . . � .............................._.._...._._ . ............... .. ....... ._.... .... --] .-- . - -.--._....-- - ------- --------------------------------_..__.. - .--- . : ...__ �`Qrdw existing and required addition.on reverse side) I hereby certify that I ha`e,pr pared 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 liven- sed agents signature certifies the following:.. I•*- - -- € certify that in the performance of the work for which this permit-is-issued;-sholl-not-employ any person in such manner. as to become subject to Workman s Compensation laws of'California." Signed _:....... . ..... . _ Owner' .. ..------ - . Title . .... .. ..... . . (I oth han;owned a I' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . r.. ...... DATE .. �y��:_ .......................... BUILDING PERMIT ISSUED ................ . ... ... DATE . .-•---.----•------:-------- `...._...... ADDITIONAL COMMENTS .............. . . . . .................................�l: .- ..._.-.. i Ty:........, .........-� ........... - . •.. ............. ..... ............ ....... -- . .._.. .. ._ •. .. -•--- Final Inspection by: .... I fr `_.. Date ......_q.. - ..7.- N JOA OUIN LOCAL HEALTH DISTRICT L3 24 ; E. H. 1-'GB Rev. 5M