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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT fPermit No, __ t (Complete in Triplicate) ® -------- -I-------------------------------- ! Date Issued ---------------------------------- ---- --- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health�tr.�ct for ,permit to construct and install the work herein t described. This application is made in complia mow' h�6. nty�"O'rd a, No. 549 and existing Rules and Regulations: ` --------CENSUS TRACT --------------- ----------- ----- ---------------------- JOB ADDRESS/LOCATIO l-L�- - ,-- " " "" " ----- ------ Phone 7,7n. - ----- Owner's Name """" ---� ---------- - = " =- _ . City r Address --------------------- eJ--- - w ! 7 aF Il; GC..�" - License_# �1_ Phone _ P Contractor's Name -___` - --- - --- 11. Installation will serve: Residence Apartment House'❑ Commercial ❑Trailer Court Motel ❑Other _____________ - ' -------------------- --- ------ y Number of livingunrtsLL____I______ Numb4 o'f ."edroorns ___ - Garbage ________-__ Lot Size .1`1 t — ----_ Private Water Supply: P�lilic,System and no a --- -- ----- - ;; ( PeatSpndy Loam ❑ Clay Loam Character of soil to a depth of 3 feet: Sand ❑ Siltt[] ` Cl-ay ❑ P ❑ If Y YP - _;gin ------ Hardpan Adobe" �FilLNlaterial yes,t (Plot plan, showing size of lot. location of system in relation to wells, buildings, etc. m st be placed on reverse side.! M NEW INSTALLATION: iNo septic-jaNz or seepage pit permitted if public `sewer is availabl'' within 200 feet,) `n _ Size _ _ Liquid Depth -------i------------------ V� . PACKAGE TREATMENT [ ] SEPTIC T=ANI,:[:='] I ------- -----------�- ------------ --------- - q nts - ----•------- Capacity'- ------- Type -------------------- Mat erial-I ------- ----- rtm Distance to,, nearest: Well _______________________________ __..Poundafiion ------ _o. __QmpProp�Line ___�-------•-.-------- No.� of Lines LEACH - Length of each line ------------------- ----- �otal Length :--------I__...--------__--- LEACHING LINE [ ] iI "DBox -Type Filter Material ______:___._______Depth .Filter Material _ _ __ _ ,Il: Distance to nearest: Well ________________________ Foundation _ Property Line -----[------.----------- 1. ------------------ SEEPAGE PIT [ ] Depth ---- Diameter _ -------------- Number!-------------------------- !tock Filled Yes Li No ❑ a bleepth ----�-----Rack Sizes } "---==_- ---- Distance to 11A ---- Pro Line ---------------------- I - ---- --_ Water Ta o nearest: Well --------------------- _ _--Foundation -------:------- P• - --------• I !. A REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------- ------ Date ------------ ---------• 1 Septic Tank (Specify: Requirements) ------------------t �l ` ----' -- -- -r-- -- cifY Re uireImeas��_ , I - - --------- ---- ---- ------ ----- ------------------ - --------- Diposal Field (Spe ------------------------- � ------ - - 4--�-�.- -_� ---------- ------- ----------------- -------------------------------------------------- - ----------------------------------------------------------- -------------------- (Draw existing and required additi n o' 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. Hoare owiner or licen- sed agents signature certifies fhe followi' - -- "I certify that in the performance of the work for which this permit is Tissued, I shall not employ any-p rson in such manner j as to become subject to Workman's Compensation laws of California." I Signed ------------------ --------- - -- ----------------------- Owner,. -------------- BY ---------------- - -Mt ------------- -- Title - -------- ---t---------- ---- (If oowner) FOR DE RTMENT USE ONLY DATE --------rjZ = APPLICATION ACCEPTED BY --- ----- l I DATE 4 BUILDING PERMIT ISSUED ------ --------------------------------------------- i- �±I.'------------- 1 ADDITIONAL COMMENTS ---------------------------------------------------------------------------i�, - -�-------- -------------- -------=-- ----,------- - ----------------------------------------------- ----------------- ------------------------------ ------------- -- -- -- ------------- - - - ---- - -- " ---------..Date -----$ Final Inspection b ---�-�----- JJJ\fMN{ AQUIN L CA HEA TH DISTRICT 9-1 7,14� E. H. 9 1-'b8 Rev. 5M �� 1�