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i r FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -----------------------------=- (Complete in Triplicate} Permit No. ~_a-___ 5-7V This Permit Expires 1 Year From Date Issued Date Issued __L---__--------- 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 _- _ _-__ `_ q - _ _ - ------------------------- CE ----- NSUS TRACT --- -��----- Owner's Name - -�Q- _,_ Phone ------------------------------------ ----------- ---•---- r , p R Address •'2- QS� .-_N'-,til`QigRT5-=-------------------- City ----t +1 P4---------- -- c .zr l , Contractor's Name CO-Nlf_ �� I4------- - -;--License•# ------------ -------` Phone -----•------- ................ Installation will serve: Residence rtment.House[] Commercial ❑Trailer Court 0 Motel ❑Other --- -- ----------------- ------ Number of living units:.----/---- Number of bedrooms _.---.Garbage Grinder -_ ______ Lot Size Water Supply: Public System and.name --- --------- :----- ------------------------------------------r------------------ ----------Private -• Character of soil to a depth`bf 3 feet: Sand❑ Silt❑ Clay;❑q Peat❑A , Sandy LoamClay,�Loam ❑ Hardpan ❑ Adobe '❑ Fill Material If yes,type _----_________-_Va_________ r f (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 seepspit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK Size________ __ _ __X �-_ { ] S?( Liquid Depth -- ------------- Capacity .1.d_aa__' -__ Type pQ _� Mafierial41�[ $ o. Compartments ---- ........� i `--F o Distance to neares t: Well 't`__ Foundation tion ---4-------------- Prop. Line _�__:t-. _____________ LEACHING LINE A No. of CirfeshRL?- __.__ Length# of each line---- _ �<. _ Total Length _____________ F/g'MR$F.D 'D' Box _ Type Filter Material QC __Depth Filter Material ___ le, % V, Distance to nearest: Well -__ Foundation Property Line _ ___________________ SEEPAGE PIT [ ] Depth_-.._, __t,:.,.__Diameter-.__-..-.__---_ Number ------------- -------------- Rock Filled Yes ❑ No i[(. Water Table Depth ___________ Rock Size - ----------------------•- ,: 71 Distance to nearest:.Weli.---------------------------------------Foundation ------------ ---- Prop. Line ---------------------- O REPAIR/ADDITION(Prev. Sanitation Permit # __y_"_ ___________________________________ Date ________.___________..__--- Septic Tank (Specify Requirements) --------------------------------:"-7----------------------------------------------------------------------- ••---------------------------- J Disposal Field (Specify Requirements) ---------•----------------------------------------------------------------------------------------------------------- --------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------- i.. --------------- ------- ------ ------- t (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 Regulatio6s of the San Joaquin Local Health District. Home owner or licew sed agents signature certifies the following: .+ `: ,4 "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 become subject to Workman's Compensation laws of California." — t " V% Signed _ _______ ______ _ Owner y 'BVI Title ---- ----------------------------------------- -(If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- t Fes* �= =+ ' ;- - ':-';.: ----------. DATE - t � E: DATE BUILDING-PERM IT-ISSUED---- „M,---------- ------ --------- ADDITIONALCOMMENTS -------------- -------------------------------------- --•-•------•---------- - ------------------- ----------------- ------------ -----------•---------------- ------------------------------------- ---------- - - -- ----- - ----------------------- -- -- P,614;1`109 - --- ---- --- - -- - -- ---- -------- ----- ----------------- --- -- --------------- -- ------- ------------------------------------------------ ------ - ----- Final Inspe tisk +: l '----------------------- ------Date --- - -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6B Rev. 5M