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FOR OFF CE USE: \„ ' APPLICATION FOR SANITATION PERMIT •f SD� `t ICampleto In Triplicab) Permit No. 7-....... .. ......................................................... This Permit Expires 1 Year From Date Issued Date Issued ' : 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 ......�r�. Q__.. ,.L./..... L ,O�I.� ....- /.....................CENSUS TRACT .......,.................. Owner's Name ' ...._. ......................................................Phone . ... Address . . s %.. '1�.,��...�i...................... cityT.�C_p,sf.. ................ ..........t.`---...-- Contractor's Name ./ TE' -._P 61.Al,,(J'/lilo.....n. .......License# ��?��'/d... Phone �•��-�T..�� Installation will serve: Residence 9?1(partment House❑ Commercial Cffrailer Court ❑ Motel 0 Other ...................... Number of living units:.._/..... Number of bedrooms ..t- .....Garbage Grinder ............ Lot Size ............................................ Water Supply: Public System and name ----•.............................._...............................................•-----....................Private Character of soil to a depth of 3 feet: Sand`Silt❑ Clay ❑ Peat 0 Sandy Loam Clay loam ❑ Hardpan[] Adobe ❑ Fill Materlat ....- - Cf >t; ::............. ............ (Piot 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 avollable within 240 feet,) PACKAGE TREATMENT [ ] SEPTIC TAP ) Size... 1?°. ...................... Liquid Depth .......................... Capacity % -.. Type - -... Material...................... No. Compartments ...................... Distance to nearest: Well _ ... .....................Foundption !D ` Prop. Line ...................... }.....5 .......... 45 LEACHING LINE [ ] No. of Lines -�.................. Length of each line.. .BGS .:. Total Length a.ZPd................x 'D' Box ............. Type Filter Material ...................Depth Filter Material ............................................00 Distance to nearest: Well ........................ Foundation ....................... Property Line .......................�I SEEPAGE PIT [ ) Depth .................... Diameter ..............-,,-Number ............................ Rock Filled Yes ❑ No ❑1 Water Table Depth .................. .Rock Size ................................ Distance to nearest: Wel( .......... ............................Foundation ----- .............. Prop. Line ..................... A REPAIR/ADDITION(Prev. Sanitation Permit# .............-----__....................... Date .................................. ) Septic Tank (Specify Requirements) ...:..-......kaOV...... ..............................................I......................... ......M Disposal Field (Specify Requirements) ..... r4Q-�^ G7` �,r -210 ------------ ------------------------- ------ --------------------------------•------------•-•--•-----------.........------•-•---.....................---- ............................... ............... ------------------------ ----------------------- -----------------•---- .................-............................................................................................ (Draw existing and required addition on reverse side) 1 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 itan- sed agents signature certifies the following: "I certify #hot in the performance of the work for which this permit Is Issued, I shalt not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signe - .. Owner BY - - -- ..-� ----f-��11�Z�-•c.•�/�1�'..�3itle - -.�.10/Il�/C�G'.TD�.-��G'�`�...-.. (If of er than owner) __- -R DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY . .. ... .------------ -- - - DATE BUILDING PERMIT ISSUED _s.- .. ..•._,. ADDITIONAL COMMENTS -----. . . .. ------- ------- -------- -------_...._. .......... ...................... ................................._....................................... .. ----------------------- ----- ....... ... ----------- ....... _.... - . Final Inspection by: ...- 1. . -----------------•--------------------•---.......;...Date .. ..'_...... .�6...!......---- 3 2h 1-613 Rev. 5M SAN .LOA IN LOCAL HEALTH DISTRICT 8/7h 3M