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FOR OFFICE USE: JAPPLICATION,FOR SANITATION PERMIT ( �--- //-�Q Permit No: - ----------- ------------------------------------ - (Complete in Triplicate) 7 I � n��w.-►�•i�N..IR�•�+•swNV�+y-�r.1 / _.•/6 p --- - -- ------------ S Date Issued Lr7 --------------- This Permit Expires 'I Year From Date Issued , Application is hereby made to the Son Joaquin Local Health District forxa permit to construct and install the work herein described. This application is made in compliance with County Ordinarice No. 519 and existin Rules and Regulations: °--------- -----CENSU5 TRACT --------------•-•-------•- JOB ADDRESS/LOCATION / '� � r - z E ^a T 7 3��• - - ----- --- ---Phon . Owner's Name �- ---� ' Address = - City - - ------- ----- � --- ILicense # �' �//� _ Phone Contractor's Name '1�" t Installation will serve. �, Residence Apartment House❑ Commercial :❑Trailer ourt';Q i Motel ❑Other - Number of living units:---- Number.of bedrooms ___ _ ___Garbdgesr+der _-___- -__ Lot e i Water Supply: Public ISystem and name ----------------- I--------;--------------------------------,---------------------------- ---------------- Private, Clay Loam 0 Character of soil to aldepth of 3 feet: Sand'❑ Slit❑ Clay El Peat❑ Sandy Loam ❑ y' Hardpan F-1 Adobe Fill Material ------------ If yes,type -- --------------------- \ } (Plot plan, showing size-of dot,-location�of-system in relation to wells, buildings, etc. must be)pl,aced on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit tpermitted if public-sewer is available within 200 feet,) V Ii uid Depth -----------• ------------- PACKAGE TREATMENT [ ] SEPTIC TANK'[ I [ Size-------------------•---�---------- - Liquid Capacity ---------------- --- Type ----------- -. Material------I--------------- No. Compartments -.---------•-•---.--•- % F�---------------Foundation ----- ------------- Prop. Line ----------_-------•- Distance to nearest: Well.................... _- � .t.� i �� Total Length ----------- ---------- LEACHING LINE [ ) No. of Lines -------`---= --------- Length of each line___--+_----------------- l _De th Filter Material _ ___5___ p .� 'b' Box .____._____ Type Filter Material __________________ , Distance to nearest:WeA _-_____ __ _ Foundation --- Property Line --------•------- ------- r SEEPAGE PIT Depth aDiameter -_--------------------- Rock Filled Yes [] No [ ] p ------- --------- Number ---., Water Table Depth ----------------- ------- ------- Rack.Size -------------------------- ' - Distance to nearest: Well _________________________ ------------ --Foundation ------------------ Prop. Line --------- ------- ,REPAIR/ADDITION(Prev. Sanitation Permit# --------- -- ------------------------- Date --------------------- ------ ------------------- ... ) Septic Tank (Specify Requirements) __________________ - ----- •-------- = Disposal Field (Specify Requirements) __ _ - ----- - I ------------------ -- - ---- - (Draw existing and required addition on reverse s e ! 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: permit is issued, I shall not employ any person in such manner "I certify that in the perFormance of the work for which this as to bec me s bject to Work n's Compens n laws of California." Signed - --=------- ----- -- � - - --------- ',��- � Owner �`L-�- - Title ------- By --------- ------- ---------------------------------------------- - ----------------- (lf other than owner FOR .DEPARTMENT USE ONLY -------- DATE - b-'R`� --•---- -------------- APPLICATION ACCEPTED BY -- ---------- --------------------------------------------------------------------- ------------------DATE ----------------------------------- ------- BUILDING PERMIT ISSUED - -------------------------------------- - ADDITIONAL COMMENTS --------------------------------- --------------- --------------- -------- ------------------------------------------------- ----------------- ----------------------------------------------------------------------------------------------------- ---- --------- - p Y- ------------ ----- - - ---------.Date -- ------ ----- ------------------ ---- -------- Final Inspection b -r--J�"e-= = -- -- - ------ - -- -- ----------- ------------------------------ - ------ SAN JOAOUIN LOCAL EALTH DISTRICT E. H. 9 1268 Rev. 5M