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I r FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------- -- - -- (Complete in Triplicate) Permit No. ----------I 4-1-i-A----------- i. _----____________ ------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued _°�_-_- Application is hereby made to theFSa 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 existing Rules and Regulations: JOB ADDRESS/LOCATION _/W/__Q_-�_2____IS_.__X_41_-,ST1 _A- V -___-_-__--_CENSUS TRACT -_______p----------------- Owner's Name --- �y /L----------7 R-------------- ----------------------= -------------------Phone �7-��-------- Address - C- /C_�.wop ---'�-�'� 1 - City / Contractor's Name ----If -------------------------------------------------------_License 0__ Phone Z—Z Installation will serve: Residence ❑Apartment Hoe us ❑ Commercial []Trailer Court ; Motel d Other _____krA/44010V '_1/0014 Number of living units:-_- ----- Number of bedrooms -------Garbage Grinder ____ Lot Size -_ -*�� Water Supply: Public System and name _______________ _____________________ Private - -------------------------- Character of soil to a depth of 3 feet: Sand'k Sift❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ 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: (No septic tank or seepage pit permitted if public se�w/er�is avail b e within 200 feet,) �� O,O PACKAGE TREATMENT [ ] SEPTIC TANK [ SizeF' ��X /f Liquid Depth __,Z/.O ______________ Capacity A.?A _e___ TypeO _7�__�>___ MaterialUVA No. Compartments r Distance to nearest: Well _4040_____------------------Foundation __ Q__________-_ Prop. Line __..__o_____....._ LEACHING LINE [LK No. of Lines __ —--------------- Length of each (ine___,J_40_____-________ Total Length ��t'50................ 'D' Box y... Type Filter `/Mat�terialAXA___....Depth Filter Material 1_�.................................... Distance to nearest: Well _!___ S_ '___ Foundation -S f_________ Property Line .................... SEEPAGE PIT [ j Depth _-__ --------------- Diameter ---------------- Number ___ ___________ Rock Filled Yes 'Q No 0 Water Table Depth ------------------------------------------------Rock Size ---------- --------------------- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) ------------------- -----------------------------------------------------------------------------------------•----------------------------- Disposal Field (Specify Requirements) --------------------------------------------------------------------------------------------------------------------- --------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --- --------------------------------------- -- --------------------------------------------------------------------------------------- (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 licen- 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." Signed --- ------ Owner By ------ ` '� Title _0 10[/� i (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------ ----------------------------------------------------------------- DATE ---- -;?C---�Z'--- -------- BUILDING PERMIT ISSUED ---- -------------------------------------------------------- -------------------------------- -----------DATE ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------------------------- .__:--------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------- --------------I------------------------------ - - - - -- ----- � ' Final Inspection by: ---------- Date -------- ------------------------------ ----------------------------- SAN -------- -- ---SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M