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FOR OFFICE USE: r APPLICATION FOR SANITATION PERMIT ---------- _AA -- {Completein4riplicate) Permit No, ._^]-Z"__�-___ R: -------------- Date Issued --------------- This Permit Expires ] Year From Date Issued f 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ------�_#_ -rJ--------- --- -- - ---- Q---t- �--��'-4•�-�- ------------------SeL'�rr'CENSUS TRACT Owner's Name ` 4- 'Y1--f'_t g4------ ----------------------- •----------------- -Phone --711E- 23T -91� - - - -------------- Address 'z,2-1-4-0---- 'Lf----J _11A------------ --- - ........------------�-----•--. City Contractor's Name -.:--_.._ !c_t^___ _E : fZ14 = __._.:License_.# == - 1 Phone =- ------------- -- ------------ Installation will serve: Residence MApartment House❑ Commercial ❑Trailer Court ❑ Motel ❑ Other---------------- + I ----------------------------------- Number of livingunits_______ ____ Number of bedrooms._- �r � �_____Garbage Grinder Lot Size _______��_______ Water Supply: Public System and..name.__---------------------- _ -------------------------------------------------- --------------------------•-----Prate Character of soil to a depth of 3 feet: San"d❑-- Silt.0 rCllaY ❑ peat❑ Sandy Loam ❑ Clay Loam- Hardpan p ❑ "�`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.) t NEW INSTALLATION: (No septic-tank or seepage pit permitted_if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] -SEPTIC TANK:[ � Size.----------------------------------•------------ Liquid Depth ------------•---------•--- �' p Capacity --- ---- Type -------------------- Material--------------------- No. Compartments --------- -- _Distance to nearest: Well '____3901' --- Foundation _ _ __1S`J�_____._--- prop. Line ___ _ LEACHING LINE [ ] No. of dines -w --- ------------ Length of each line---------- ©----------- Total Length ---A-V ............. 'D' Box ------------ Type Filter Material ___________________Depth Filter Material --------------------- V ---------------- ' Distance to nearest: Well ..__...3-s0 ___ Foundation -O/ -_- property Line O -------•---------------- SEEPAGE PIT [ ] Depth _-______.____.-_-_ Diameter ________________ Number ._._ -------------- ------ Rock Filled Yes ❑ No I❑ # Water Table Depth --------------------------------- ---------------Rock Size ------`------------ ------- - Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------------_- --- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date Septic Tank (Specify Requirements) -------- Disposal Field (Specify Requirements) ___ P --------------------------- ---------------- ----------- ----------- -- - - -------------------------------------------------------------------------------- (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 ownet or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed _.__ ,f, _ V ----------- Owner r - - --------------- By ------------- - - - - - n ------- -------------- Title --------------------- - ---- - - -- - - --- - - ---------------------------- - (If other than owner) ------------ ----------- -------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ DATE ----------------------------------------------------------- DATE/_._-!!J ISSUED ------------- DATE ---------- = t ADDITIONAL'COMMENTS ----------- s ----------------- - - --------------- ------- ------------------- i ------------- -----------------= -_______________________ __________________________________________________________________________________________________________________________________________________________________________________________________________ Final Inspection by: --------------------------- -----------._Date - ----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. q .1-'6$ Rev. 5M