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FOR OFFICE USE: " APPLICATION FOR SANITATION PERMIT -------- ------------------------------------- __ f ( (Complete in Triplicate) Permit No. ________________________ ______________________________ This Permit Expires 1 Year From Date Issued Date Issued ✓ .7� 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: p p ; JOB ADDRESS/LOCATION .--- - l.l�_-C- ,.5------ a -I -- ---- `�--------- =-----------CENSUS= TRACT --- ---------------- -- `- ----- Owner's Name ±IIR1Q /�f5- ----------------t----------------Phone ------------------------------------ Address �� F -S------------R-0134eER__T City ------- }- '------------------p-------------------------l--/ Contractor's Name ---- -_, ... .---- R_1Cx1_ --•-----------------------------License # V3- ��--- Phone Installation will serve: Residence ff�rPartment House❑ Commercial ❑Trailer Court ',❑ Motel ❑Other -------------------------• ----------------- Number of living units----- ____-_ Number of bedrooms _______Garbage Grinder 01� ---_ Lot Size ----A_c Rff}_6- ----------- Water Supply: Public System and name ------------------------------ ------------------------------- --------•---------------------------------------Private Character of soil to a depth of 3 feet: Sand❑ S 3 ilt❑ Clay ❑ Peat Sandy Loam ?]Clay Loam ❑ _a y ,�j Hardpan ❑ Adobe !] Fill Material _ eD__ If yes,type ____________________________ a r (Plot plan, showingl-iil-e'of-Tot,- location bf'-system in relation to wells, buildings, etc. must be placed on reverse side.) NEW PACiCAGE'TR TREATMENT SE (No septic r seepage pit permitted if public sewer is available within 200 feet,) c tank o [ TANK'[ / v Size `r:F ----•------- ------- ----- Liquid Depth ------------------- # � C3 r3 i1� — (� Capacity fTYP L -------- 1llaterial------ ' No. Compartments I ------- - Distance to nearest: Well ------------------------------------Foundation ----------- --------- Prop. Line ----------.-----.----- LEACHING LINE [ ]) No. of Lines ------ ----------- - -Length of each line----------____'_____..______ otal Length D' Box ---------,_ type FtItei Material --------------------DepthFilter Mate al Distance-tnF r-est:'WWell i------------------ FoundationF __________ --_ Property Line _______.__._...._....... SEEPAGE PIT [ ] Depth -------------------- Diam ter ---------------- 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 _________Se tic Tank (Specify Requirements) -------------------- - ----------------------------- -- _ ----- --- __-- Disposal Field (Specify Requirements) _ ` �- 4 __.Q _ ____ '14N .--- f--- - QD-_.__-��/4L�------ DniC --_ �Q_ ------G__F_P Kt `rl� ------------- 7.71.6�fT L.N IJAPEf;-------- ,oA� J00 0 Ql --- LAC -- 1. ^ _ �f� -= (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 certit tin perfo nce of the w k for which this permit is issued, I shalPnot employ any person in such manner as to e s ct to,�5 kman's Com cation laws of California." Signed ---------`------------Q --- -----------. Owner 1 �� By ---------- ----------- -------------------- ------------------------I-s-- _P_' Title ' _==t- t ` ` ` (if other than owner) c� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- i t�' r� _ --------- ----_-- -------------- DATE ----- ^gip 7 ---•--- _ ._PERMIT ISSUED --------- ---~-------------------------------------- ---- • -- --------- -------------------- --=------ - "DATE-------------------------- ADDITIONAL �=-------------- ' �, COMMENTS ._- _S_ +-=�c� S ----------------------------------•----•----------- ------------------------------------ --- -- -- ------ --- --- --------------------------------- ------ -------- Final Inspe ` PA - Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6B Rev. SM