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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ICompleN in Triplicate) Permit No. .7�. Date Issued Z� �o :Zc ....... ..A:al:::�...................... This Permit Expires 1 Year from DaN Issued Application is hereby made to the San Joaquin Local Health District for a permit to conshud and instal) the work herein described. This application is made in comp�77 with County Ordinance No. 549 and existing Rules and Regula ions: JOB ADDRESS/LOCATIOPI ....I..g. ,Q .!'-Y/...N.,S. ..4.¢•-..,.... .CENSUSi TRACT ., . Owner's Name . .�.:..�! !�1 'b. '.42.................................................. .Phone ...V--64,94-e7. Address ..... n. !�'t.4�...., ,..a �0r.... .4'�. ,..aty ...��!o-c� ..... ............. ....... ........................ Contractor's Name A.,.a.,..Pa ,- ..................................................License .r ,S .. Phone i .......... installation will serve: ResidenceXApartment House{] Commercial[]Trailer Court E3 Motelp Other ............................................ Number of living units:......I..... Number of bedrooms .....Garbage Grinder ............ Lot Size 44n :04--f6a, ......... Water Supply: Public System and name ........................................................_.....................:..............................Private Character of soil to a depth of 3 feet. Sand D Silt 0 Clay 0 peat j] Sandy Loom 0 Clay Lam Hardpo*Ad_ Adobe J( Fill Materlal 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,) PACKAGE TREATMENT [ j SEPTIC TANK ..�.�.�. 8.�................... Liquid Depth ...�.........�...... Capacity -�:�'4.0..... Type P�� Material. ..... No. Compartment: ....tQe.......... Distance.to nearest: Well PA &.-.V. ..................Foundation ...../©......... Prop. Line .....................-10� LEACHING LINE No. of Lines,,,3................... Length of each line....../74e. ........... Total Lon ........ 'D' Box ...i.--.... Type filter Material ..Depth .Filter MaterialI.&.1!............................... r - ---—------ Distance to nearest; Well .1.5.x............. Foundation ..../..D...-'........ Property Line ....... ....... SEEPAGE PIT Depth ... 'Z. ...... Diameter . R -:. Number .. .............N.. " Filled Yes IM No Water Table Depth .........LOT.' ............................Rock Size ..t. -.. .`.�... Of Distance to nearest: Well .....�.. .' .I ..................foundation ......410.... Prop. Line ... 0'... Ap REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................) Septic Tank (Specify Requirements) ..........•••................. --•--. .............................._.........:....................... ........ .......... .... DisposalField (Specify Requirements) ................................................................................................. ..................:................ ..---..................,---••-•----..........-•---.......:._..........................-------•......--...........-----........ ....,.................................................................... ..• •--•-••----------••--•---•-••--•-•-•-----•-•..................•-•. ..............,............_........................................................................................... . (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that da work will be done in aaerdance with Sen Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Hear Dlsirid.Meme owner or liasn• sed agents signature certifies the following: "I certify that in the performance of the work for which Ibis permit is issued, 1 shall not employ any person in such manner as to beco a subject orkman's Com ensation ws of California." s,.., Signed _.. ......4..Q..... _. ..�►'-: �}�' .................................... Owner ...... _...._.... - ---• Ar-. ...ev.................................. (If other than owner) EPARTMENT USE ONLY APPLICATION ACCEPTED BY .._��Z_f : — .---- - ---------------•---.........----- - •-•-•-------.-.----. ...-----• DATE //.,.. .�.�.': ....:BUILDING PERMIT ISSUED ....... ........ .. ................................... .............. ..DATE --..... ............................ ADDITIONAL COMMENTS ....................................... ... ..........,....... •.. .......................... Final Inspection by: ...... .............��.r.._. _--•• QUIN - ........................ ......... .................. ,�✓ d� EH 13 24 1-6o Rev, 5m JOALOCAL HEAALTH DISTRICT Date � 3M