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FOR OFFICE-US G°o APPLICATION FOR SANITATION PERMIT ----------- (Complete in Triplicate) Permit No- --------3 ------------------ This Permit Expires ] 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 cymliance'with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC TION .__.--.-_. T - -----_ ----------------------------------- -_-�i�yES j CENSUS TRACT __________________________ -- ---- Owner's Name ..7.PO�t - -------------------- Q -109_------------------------------------ -------Phone -C------ - --- ----------------- Address -------5-5 Cit Yp Contractor's Name ..._ ___ - ___ --------------------------------------------------------License #49S_. ' Phone _ ..... .... Installation will serve: Residence [ �aaartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other Number of living units.-,/-------- Number of bedrooms___,_Garbage Grinder Lot Size - __ __ C) 6l� ------------------------ Water Supply: Public System and name ----------------------------------------------------------- ------Private Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑, -Peat❑ Sandy 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.) \t- NEW INSTALLATION: (No septic tank or seepage-pit permitted if public sewer is available within 200 feet,} V v4 � Sir / PACKAGE TREATMENT { ] SEPTIC TANK [ Size r-I__ lC - -- _ - ---- ---- Liquid Depth ---�--�-- ------------ � . Capacity --- Type� 'P_«�i/Materials-Q' � e-No. Compartments p --------- Distance to nearest. Well ------5_p-------------__ _____Foundation ...1_f7--___. Prop. Line ___�� -_-._._-_ LEACHING LINE [44 No. of Lines ------- --- --------------- Length of each line.......90--_-.-- ----- Total Length �_�D------------ 'D' ---__ _-'D' Box /-------- Type Filter Material-O?C. �_.�_Depth Filter Material --____I9 <. Distance to nearest: Well ______________ ___ � f ---_---_---- Property Line 5 ----Foundation - ---------- - ---------------------- SEEPAGE PIT [ Depth ____________________ Diameter ---_-____.__ Number ------------------._- Rock Filled Yes ❑ No i❑ 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) ---------------------------•----------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------ --------------- ---------------- - - ------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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 bec a subj t to Worm's C pens,p i d laws o California." Sig -�-- Si ed � f /-C---��? --'S---- -------- Owner � By �+. ._/n_Q 11-- ---- --- -- ` 2 �� Title - -- ---- ------- (I other t o er) ----------- - ------------------------------- FOR ------------------ - ------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ..__. . BUILDING PERMIT ISSUED ------- ----'- - --- --'�-- ---------------- ----------- - ---------- - - DATE --- --/1.--/S��------------ ---------------- --------------------------------------------------------------------- ----------DATE ADDITIONAL COMMENTS ------------------------------------------------------------ ----------------------------------------------- ----------------------------------------:----- ------------------------------------------- - - -- - - -- - -- -- - - - - - - - - - ------------------------ - - -- - - -- --- -------------- -- ----------------------- - ----- - --------- -- - - ---- Final Inspection by: -------- - - 1 - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M