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FOR OFFICE USE: •� /�///, a APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. - ---------------------------- ------------------------- 7 This Permit Expires ] Year From Date issued Date Issued Application is hereby made to h��a uin ocai ealth D�trict 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 . ---�/,------ i�S �, / (/ (�'] / I ze - ------------CENSUS/TRACT Owner's Name _r✓.=1/`4 / U_Sr - �+ �f_ ----- - ---- Phone ------------- Address Pu 0,--- 7l fIt, Q ------------------------------ City - /_ ll -------- Contractor's y-----------------�---------------- Contractor's Name ____a?".j-:=__------01-212" __/-2� }�ip .License +.a-ye __`d-_ Phone d24?-_ ?� Installation will serve: Residence ❑ Apartment House,0 Commercial ]Trailer Court ;❑ Motel 0Other -- Number of living units:------------ Number of bedrooms ------------Garbo a Grinder _________-- Lot Size _ - - ------------- --- ------- Water Supply: Public System and name __________________ ____ ------- ------------9------------- -----------•---------Private --=------------------------ Character of soil to a depth of 3 feet: Sand'X Silt❑ Gay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ } -r-= Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ----------------------- bV (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) d NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size--- 1 -�--�� --�--- - ----- Liquid Depth ---�.�--'------------ Capacity _Poo------ Type �7jP� -- Material_ No. Compartments � Distance to nearest: Well �_ --- / b Foundation --------- Prop. Line _S ............ LEACHING LINE [ ] No. of Lines _ ----- __ Length of each line______ _ CcS�O ------- Total Lenges :---cf_--- _f........... 'D' Sox ------------ Type Filter Material _____P-'-----Depth Filter Material -,IR-** Foundation ____�D Distance to nearest: Weil ____ _________ Property Line. __ ___ PIT SEEPAGE_ C 1 Depth --------------------- Diameter ---------------- Number ------------ ----- �. _________ Rock Filled Yes ❑ No .c] , 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) _f�_R---- coq - Hp5€- Y --------------------------------- - ----------- --------- ` - ---------------------------------- ------------------------------------------------------------------------------------------------------- ---------------------- - , (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 _ ---- ------------------ ----------T--. Owner ----------- Title ------------------- w� ------ a other than owne ---- --- FOR .DEPARTMENT USE ONLY'A"�+.,�i 9e APPLICATION ACCEPTED BY ._ _ ------------ ------ -------------- A----------BUILDING PERMIT ISSUED ADDITIONAL,CQMMENTS ------ ------------------------------------------------------------------------------ {-------------:DATE ------ -71 -------------------------------- - - -------------------------------------------------------------------------- -------f,____Final Inspection by: _____ � _----------- SAN JOAQUIN LOCAL HEALTH DISTRICTa E. H. 9 1-'h8 Rev. 5M r