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FOR OFFICE USE: „ N. APPLICATION FOR .SANITATION PERMIT .................................. Pe7Y,, No, {Complete in Triplicate) x ... This Permit Expires 1 Year From Date Issued Date Issued ..9'_4.1 .:.73 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,(Jrdinance No' 5 and existing Rules and Regulations: JOB ADDRESS/LOCATION / --.. s..... ......u'!-'-----...._ !i.t7..CENSUS TRACT .......... Owner's Name i_.61-S.......�Zar.q,1S..----•--•-•--.... .........................Phone .................................... Address ...................... .. f 4QJ." /1Plf t_�✓ Q. -------. City . ....___.................... ...... ............... Ici .....____.License # �_2�, %_'Phone .. L_ Contractor's Name ---• � -•............. cz..._ ...-��4ment ..................__'C} 'CI ❑ -................ Installation will serve: Residence House Commercial O Trailer Court Motel ❑Other ------ ..................................:. Number of living units:_...J.-_ Number of bedrooms ___L......Garbage Grinder .AbR_. Lot Size ____________________________________________ Water.Supply: Public System and name ............................... . .....................--.... .......... ----------------------------------.Private ❑ Character of soil to a depth of 3 feet: Sand=j Silt❑ Clay ❑ Peat 0 Sandy Loam Clay Loam ❑ Hardpan ❑ Adobe'[] Fill Material ..... yes,type ____________________________ 4 (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,j i PACKAGE TREATMENT SEPTIC TANK Size................................................ Liquid Depth ............................ Capacity Type .... Material___________________- No. Compartments ......._:.............. � Distance to nearest: Well ................... ___........Foundation .......... Prop. Line .....................�,. LEACHING LINE [ } No. of Lines ............ ---------- 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 0 LP Water Table Depth Rock Size Distance to nearest: Well ________________________________________Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# .................. Date j Septic Tank (Specify Requirements) ------------................... .... '_. ........ ------� ----------- �_ ---- .; . ....... ... Disposa Field (Specify Requirements) ------ ----=--••---- ....._ __ .------------ r n � r --•--••--- a � ��`! ._.. lPr4�--••----------------------•----•----------•-----------------------•------------_-,_---.,-----••--'--•-------•----•-•-••--- ------------------ ............................................ ------------------------------------------------------------•--•-----•-----___-•-•---••--••--------•-•------•--------•----•-••-•••------•-•=--••-----••- (Draw existing and required addition on reverse side) r 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 licew 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 Workman's Compensation laws of California." i Signed - •-- Owner f - � By •--- •--•--•--- -• :............4 ..�`-----------------•--------'. Title ...._ _..........._..._._. ... ._. _.. .. . . ....... (if of er than owner} FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .................... DATE6 " x.3......_.-_. BUILDING PERMIT ISSUED ............ •-•----•........................DATE ...................................... ADDITIONALCOMMENTS -----•-----•-------------- ............................................................. ............. -- -- ------------------ Final Inspection by: ----•---�._._ ............. ........ -----•.....:..............................Date . _SAN,JOAQUIN LOCAL HEALTH DISTRICT C.`a