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FOR OFFICE!USE,? APPLICATION FOR SANITATION PERMIT (Complete in Triplicates Permit No: _617=,_1 ___------------------------------------------------------ This Permit Expires 1 Year From Date Issued Date Issued-3_12V__7&.5? Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and .Regulations: ION _ JOB ADDRESS/LOCAT /` .1r _ ____ �C _____Ia_.��T_r)--.-"---.--CENSUS TRACT•----�__________________ Owner's Name �T 1ll�R_��` Dam<_�i�Q/� Ph1one Address --------� 7rG_._ _ �r0'I F ------R-Y--------- City _:_J�AA jo _1L--'---- ----- -------------- Contractor's NameQ1�KD�.�- :_ C$_ T ---Pl'_ ' -� ---C -- ------License # -- ----- Phone ------ ------------------ Installation will serve: Residence g?Apartment House-[] Commercial :E--]Trailer Court Motel ❑Other -------------------------------------------- Number ------------- ----------------------------Number of living units:___f------ Number of bedrooms __3____.Garbage Grinder ---- Lot Size __13�C3_ _64F—.-..________ Water Supply: Public System and name .------------------------------------------------------------ ------------------------------------------------Private ®� Character of soil to a depth of 3 feet: Sand 7] Silt❑ Clay ❑�. Peat❑ : Sandy Loam ❑ Clay;Loam,s❑�_„r�e Hardpan Adobe'❑ Fill Material IV - 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) �l PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------- ------ --------------------- Liquid.. Depth ----------------------- 6\ -------------------- TYPe.-------------------- Material---------------.,----- No. Compartments (� Capacity - 1 Distance to nearest: Well ________________________________:__Foundation ---------------------- Prop. Line ____-______-______-___ LEACHING LINE [ ] No.of Lines ------------------------ Length of each line------_--------------------- Total Length ,___-____________----_--_-__ f � 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------------_----_-•-----•-•----_--._-.- �+ Distance to nearest. Well -__---------------------- Foundation ---------------t--_.-_ -Property Line -- I SEEPAGE PITT [ ] Depth -------------------- Diameter ---------------- Numbe ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth --------------------Rock Size -------------------------------- Distance to nearest: Well _______ ________________________________Foundation -------------------- Prop. Line --------.-___--_______ 1 REPAIR/ADDITION(Prev. Sanitation Permit ..............,-__ ------------------------- Date _-_____-____-___________-___-__--} SepticTank (Specify Requirements) ---------------- ---------------------------------------------------------------•--•---- --------------------------- Diispo§ql, Field (Specify Requirements) -----/AL_ �-TA44 -------PRE-r4_15______GX?1 _RF__T''a.._______l --- `M K `Tb -----�'_t.._C? T 1 ------------------------ . (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 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 becomes`b' c_to-Wor ma p Co nsati.on la ► o California." Signed --------------- -' caner ---- ---------- --- ------------ ------ BY --------- ---------------------- --- ------------- ---------------------------------------------- Title -------------------------------------------------=---_----------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- ----------------------------------------------------- --------------------- DATE ------ ----/-y_'-Zy--------- BUILDING PERMIT ISSUED ^ = =" -------- – _ _ DATE------------ - ---------- ADDITIONAL COMMENTS ----- - - -------------------------- -- -------------------- ----------- ----- ADDITIONAL ------ - -------- -- -- - - ----------------------- --------------------•--------------------------------------- ------ ----------- ------ ------------------ - - ------ - --- - ----- --- ---- -- -------------------------------- -- = �3 ---------- Final InsP ��--- -------------------_--- -------------------- .Date ---- T-j - - SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H. 9 1-'b8 Rev. 5M.