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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------ -------------- r --- Permit No: ! (CompleteinTriplicate)-------- r--- . Date Issued ---------- ----- This Permit Expires 1 Year From Date Issued y 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 ma in compli with County Ordinance No. 549 and existing Rules Q Z� Rules and Regulations. SA� 57CTJOB ADDRESS/LOCATION r ti Owners Name -.-lJ I '� � 7 - L-=L— --------------- Phone Address -------- ----------- 5 t ------------ City s - -------License # 1?3- ------ Phone - ------S--�G-/ --------------- Contractor's Name ------P-4_- -'��-- ----- t�'_s�t._ - �----�--�-------- -- - - - /� l Installation will serve: Residence ©l partment House❑ Commercial:❑Trailer Court ';E Motel ❑ Other �- ---- ; ` Number of living units:_________ Number of rooms --____IGarbage Grinde tot Size __ ___-_ y-�� ------•.- Water Supply: Public System and name --- ---- - ---------•--------------- -- ----Private ❑ 4� Character of soil to a depth of 3 feet: Sand'❑ Silt Cl ❑ I Peat❑ Sandy Loam ❑ Clay Loam ❑,. Hardpan ❑ AdobeFill Material __ if yes,type'___________________________ . (Plot plan, showing size of lot, location of system in lation to wells, buildings,. etc. must, be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewers available within 200.feet,) PACKAGE TREATMENT [ ] SEPTIC TANK. S' e __ Lquid,DeptliIz,_______._=_. Capacity I _.___ Type 0__ _ Material_ ____ Co. Compartments __ ......... Distance to nearest: Well _.________--------------Foundation ___ -f__-____ Prop. Line - _---______...._. LEACHING LINE 'M No. of Lines ___�____.____.___ Length of Peach line----fl,5 ------- Total Len th ,_ d__-__-_____._.. � - 'D' Box ____ ____.__ Type Filter Material � __ .c' --___Depth Filter Material _ ---__------------------------------------- Distance o nearest: Well ___�~____, -__ Foundation __ __ ___________ Property Line -�=____�_---__-_.__. SEEPAGE PIT Depth - ______ Diameter vNumber ----- - -------------- Roc; Filled Yes No i❑ [ Wafter Table Depth --------1r?Q-- ------5------•---------•--Rock Size .�1 -------- Distance to nearest: Well _____' `-------------------Foundat.ion ----��.!__' Prop. Line `..-____---_:_ REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------- ------ Date ----- --------------------------- Septic - •,-,,-.,----:_-----------Septic Tank {Specify Requirements) ----- --------------- ------------------ !------------------------------------•----------------------------- i Disposal Field (Specify Requirements) -------------------------_- ------------------------------------ ` _ i i -------------------------------------------------------------------------------------------------------------------------- _________ _ ---------------------------------+-__._.______________--____F -------------------------------------------------------------------- (Draw exis ng and required addition on reverse=side) z _ 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 licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit-is"issued,-1-shall not employ any person in such manner as to become subject to Workman's Compensation laws of California.'; Signedg ------- --------------------------------- - -- ------------ ---------------- Owner if4 1 � 12. By --------- --- ----------------------------------------------- - -xit. (if other than owner) F DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- -- ------ -- -----------=------------------------------------- ------- DATE _._�-_��=----- ---------- BUILDING PERMIT ISSUED ------ ------------`-------------------------- ------.._DATE - ------------ ---------------------------- AD ITIO AL COMMS TS / +--------------- - ------ --------------------------------------------------- - ------ -------------------- - ----- --- 6 ` ?�- --- ------ -------, � --�=-----��-�-,-L-�-- ;/---/�� -------------- ------------------------- - ----- - - � ? ' L - ------- - --------------------------- _ - Date = ---------------------------------- -Inspection by: .__.. N JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Re . 5M