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n i FOR-OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------ > - , . �/ :f Permit No:72,_6 L� (Complete in Triplicate) Date Issued ------__---- This Permit Expires 1 Year From 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 Ordinan eslo.,549 and existing, ules and Regulations: ' JOB ADDRESS/LOCATION /I ---�SQf-:°1�'---SIL✓ -Ll-D-�/--l. _S/S_5W ®f"_ -- CENSUS TRACT ---------------------- --- Owner's Name -. ------f V.O----- , ©r------------------------------ -------------------------- -------Phone ---------------------•---------_---- Address ---=1529wc-------------------------------------------------------------------------------•--• City --------------------------------- --------------------------------•-------- Contractor's Name ----------------------------------------- License # 127_57"13---- Phone�Wle4 Installation will serve: Residence FDApartment House❑ Commercial : Trailer Court '❑ Motelli'Other Q07--VQQ1Z-------f5P4__ c-.0 Number of living units------------- Number of bedrooms,------------Garbcge Grinder.------------- Lot Size ___--_-----------_------------------------ Water Supply: Public System and name ----------------------I----------•------------------------------------- --•-I------------------ -----._--------Private-K r Y Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat El Sand;Loam ❑ Clay Loam Hardpan ❑ 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) iO ` �� ---- ---- -- Liquid Depth ------- PACKAGE TREATMENT [ ] SEPTIC TANK0 Size.- -- -_- _ - �-` t ' [ g� No. Com arfinents _ .................. Capacity -- Type - Ma#ena _ p 4 .-. Distance to nearest: Well-__-------------------Foundation - ------------- Prop. Line ----------- l LEACHING LINE J.,J, No. of Lines ----/---------------- Length of each line-.---/_47fJ/---------- Total Length / ---._--__--_-_....-_ 'D' Box ----------- Type Filter Material -------------i-----Depth Filter,Materiai ------------------------------------•--- Distance to nearest: Well ---------------------- Foundation-+------------------'---1�-- Property Line ----------------_----- SEEPAGE PIT [ ] Depth ----_-------------- Diameter ---------------- Number -------------------I---- !_- Rock Filled Yes ❑ No 0 WaterTable Depth -------------------------------------------------Rock Size -------- ----------------------- Distance to nearest: Well --------------- Foundation -------------------- Prop. Line _----_____-__.__-_--- REPAIR/ADDITION(Prev, Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ------------------ ----- ----------------------------------------------------------- Disposal Field (Specify Requirements) ----•--------- ----------------------------------------------------------------------------------------------- ----------- s --------------------------------------------------- -------------------------------------------=l---------------------------------------------------- ------------------------------ (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 F as to beco/subjeo Work ' Co pensation laws of California." Signed --- - ----- --- - - ------ -------------------------------------------- Owner------ Title ------------------------ - --------------------------------------------- t owner) 1 FOR DEPARTMENT USE ONLY q APPLICATION ACCEPTED BY ---------------------------- - DATE ---�"'------�ry�-------------------- BUILDING PERMIT ISSUED ----------- ---------------- -- DATE ADDITIONALCOMMENTS -------------------------------------------------------------_------------------------------------------------------------ --------------------------------- �„ti��1 r� �cab ------------------------------------------------------------------------------------------------------ -- � T -9-- t+----- - J- --- --------------- ---------------- --- -- - --- - - - �.� - - 1 1 --------------- Final Inspection by- ---- Date - ------------------------------------------------------------------------------ ----- -------- --- --- ---- ' SAN JOAQUIN LOCAL HEALTH DISTRICT t CG I E_ H. 9 1-'6$ Rev. 5M