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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete In Triplicate) ..................................... :...._: Permit ................................ This Permit Expires 1 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: i JOB ADDRESS/LOCATION ........I- ..' .LS..__V1.rjq •_... .At ..........................................CENSUS TRACT .......:.:._.:::.....W.... Owner's Name ----------------®.(:jL_►r'r/Y.. ..+ ?r ..............................,-• .....--------- ---•--..........Phone ...........:........ Addressf_ �.. .. ........... '_.. _-__-.---•- City _. .............•-•--............ ................................. Contractor's Name ------ "_L._�. .Y T. '• --••-•=_-f�: ------License # �.. � Phone1 !.�-�.(a` r... Installation wiil;-serve------ —Residence Ufl•Apartment House-fl-Commercial-❑Traller-Court 0— -^- Motel [)Other ............................................ i Number of living units:..... -._... 'Number of bedrooms ....3.....Garbage Grinder ............ Lot Size ............................................� Water Supply: Public System and name ....................................----------------...........................................................Private ❑ Character of soil to a depth of 3 feet: Sand Slit❑ Clay ❑ ( Peat❑ Sandy Loam ❑ Clay Loam 0 i Hardpan jZ Adobe '❑ Fill Material ---------_ If yes,type ----------------------------- V1 (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 publlc sewer is available within 200 feet,) _ f� PACKAGE TREATMENT [ ] ± SEPTIC TANK ,t�] Size..__ ? _`AIZ" ..................... Liquid Depth .......................... .. - Capacity JA11PQ._.._ TYPe rc c Materi _�,'.y¢ .G L�t No. Compartments :..:.. ............... Distance to nearest: Wel( ------------5C2..........:.......Foundation -------/O...._...... Prop. Line ../.t�.............. LEACHING LINENo. of Lines ....... Length of each line---------- ...:......... Total Length ..Z20!.............. 'D' Box --- Type Filter Material .5:4. Depth 'Filter Mdteria) _ ,.,,.1:= Q ...... Foundation 011 - ..'......__.._- Property Line 1p '........... Distance to nearest:"1Neii ,_. I SEEPAGE PIT ( Depth ..____X5..-._.. ^Diameter ..:: ...... Number -.-_-______.-�............. Rock Failed .Yes No 0 Water Table Depth ....Rock Size ---------- Distance to nearest: Weil ........ ...... .........Foundation ......16......... Prop. Line .... .......... REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. SepticTank (Specify Requirements) ......................................__..................-............................................_........._....------------•....... DisposalField (Specify Requirements) --------- ......--......................-....................................... -----•-------------------------•--•-------------• .........................................-•-------------------------------------------- ------ ..................................................................................................... ....- ---------------------------- --------------------------- ------------------------------------------------------------------------•.................... (Draw existing and required addition on reverse side) 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. Homeowner 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 become subj t to ork 's Compensation laws of California." I Signed .Lam' , ..._ ------ ------- Owner ................. .............. .. . . ---... lila (if other than owner) a ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ... . ........ .. . . ---•- -------.......---.........._._.....--••-.....__._............. DATE .rS�.-.. .�.�..._......:........ I BUILDING PERMIT ISSUED --•-•-.-•---••----•---- " .. DATE .... ADDITIONAL COMMENTS ........ ..................... ------........ - - --•.....................•-•---------._............__........._..---...----•---•---••-•-••-- ----------------------- - - ....... ...e ....... Final,' spection by: ---------•..............•---•--........-----••--.................• Date rs`'. .:.. ... ........... SAN JOAQUIN LOCAL HEALTH DISTRICT r E. 8,1.3:,24 I-'68-Rev. 5M_ 7/72 3 M