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FOR OFFICE USE: APPLICATION ICOR SANITATION PERMIT f% _. . .s.................................... (Complete In Triplicate) Permit No. .. t �Z . ...J.... ... This Penult Expires 1 Year From Date Issued Date Issued Vm— Application is hereby made to the San Joaquin Local Health District for a permit to constnlct and install the work. herein described. This application Is made In compliance with Co my Ordinance No. 5+49 and a istln Mules d R ul6 Ions, PP � t`f7S s j $��4E rrz� �rr��r �'� �fj�� O /� 'moo• 4A ,SOB ADDRESS/LOCATION ... .:...............4 ... Lis-,�? ........................ .CENSUS TRACT f Owner's Name WeeL."ttw. .:_....__.... l7Gt r�.. .... .Phone .................................... Address -7---.... _ �F ll` `.fr ..............City ....................... ......I............... Contractor's Name ..... '••- ---••---•-•-----•--•---------•--•-------- ........License # 2,4:: . Phone .3EE 6, Installation will serv@3 idence Q Apartment set] Commercial ❑Trailer Court ❑ Motel❑Other.2iii ........ Number of living units:----------._ Number of bedrooms ............Garbage Grinder ..___....... Lot Size ............................................ Water Supplys Public System and name y-----•-•--•....................-----•---------------------••......................................-----._Private ❑ Character of soil to a depth of 3 feet: Sand❑ -Silt❑ T~Clay ❑ Peat�] :Sandy Loom ❑ Clay Loam ❑ ,. - Hardpan❑ Adobe 0 Fill Material ............If yes,type............... ..... = I (Plot plant, showing size of lot, location-of-system in relation to wells, buildings; etc. must be placed on, reverse side.) cel NEW INSTALLATION, (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ SEPTIC TANK[�j,� Size................................................ Liquid Depth .......................... Capacity .1 D'.. l Type Material...................... No. Compartments ..`r- ............... Distance to nearest.• Well ....................................Foundation . Prop. Line LEACHING LINE [ ] No. of Lines —................. Length of each line... .!.............. Total Length -I41-A/............... 'D' Sox ......... Type Filter Material ._ nr-�e' -__ _Depth Filter Material ... 4! .....................I........ • ! Distance to nearesh Well Foundation ........................ Property Line ..................;..... SEEPAGE PIT Depth -------- ------- Diameter Number _..._._..--.__...__......... Rock Filled Yes ❑ No CIV 'Water Table Depth ----•...........................................Rock Size -•-•---.. ............... Distance to nearest, Well __............................ .. .......Foundation .................... Prop. Line ......................... REPAIR/ADDITION(Prov. Sanitation Permit# ............................................ Date ..................................I SepticTank (Specify Requirements) ................................................................-...............-------------............... ..........._................. Disposal Field (Specify Requirements) '.. .....---- ------------------------------------------------------------------------ ...... •--•-----..........----• -•---.....---------•-•---.............................................................. (Draw existing and required addition on reverse side) 1 hereby certify that 1.have prepared this application and-that the work will be hone In accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Ilton• 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 .....4 ............... -------------- Owner By ................. ... ....---------.. .....................-•-------..._-_----•---- Title ........------.....................---................_........-...... 4�1 (If other than owner) I R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _.. .. ... . DATE �` ..............................'•'- BUILDING PERMIT ISSUED ........DATE ....-•---•--.....-----•------------=------• ADDITIONALCOMMENTS .......................... .. ---..--..........._....................-...-----... .......... ... ---------- --- -- ......-- .....--------............. ..... ..... ...... ... . ................................... ......... I............... . Final Inspection by: Date -..... .,..'� �I --- ..... .... ............................. ........... ....... —................... � .. .. 13 h -6o V• SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3M