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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -- ------------------------------------------------- / % (Complete in Triplicate) Permit No. ------ --------------------------------------- ----------------- ---------------------------------- --________________ _-----------------------_---------------- This Permit Expires 1 Year From bate Issued Date Issued h'_X__ .. 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 Co my Ordinance No. 549 and existing Rules and Regulations: Co • �['��%a n JOB ADDRESS/LOCATION -- -------&'_--Qw---_-- -----------CENSUS TRACT , Owner's Name ----v C /= - f}x'Sof ---------- - ---- ------- ----------------------------------------- - ------------ ------Phone --.� _��b,6--- ' Address ----/7/-4`b-------`S< Q_Y14n ----e ee_5f------------------------- S a/ Contractor's Name T -L! �i- /�L h."4------ ------Licensee------ Phone Installation will serve: Residence [ partment House❑ Commercial []Trailer Court Motel ❑Other -------------------------------- Number of living units:.----- Number of bedrooms _',3_-------Garbage Grinder 4N..... Lot Size �_ ----- ----------------•-•--- Water Supply: Public System and name ------------------------------------------------------------- ------------------------------------------------Private P Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ ClayNLoam.;P/ _Hardpan.. ,,„Adobe. Fill Material _____________ If es (Phot plan, showing size of lot, location of system in relation to wells, buildings,-etc, must be placed on reverse side.) N\ NEW INSTALLATION: {No septic tank or seepage pit permitted if public:sewer is available within 200 feet ,) v PACKAGE TREATMENT [ ] SEPTIC TANK1 __ _._ s ,] Size____ ��--�//�� --��---------- Liquid Depth ----�-Q-------..------ Capacity _� -a_#-- TYpe /eQC'f�`. _-- Material_LR? � �4C_ No. Compartments ----- ..-t. --•-_ Distance to nearest: Well _______,7 P---------------------Foundation .___ ----- ------ Prop. Line ______ ___ ------- LEACHING LINE [ ] No. of Lines ___~P Length of each line______ � € + .4 . r._< Total Length .� .- 4 ZZ r 'D' Box __,�------ Type Filter Material _EJG�________Depth Filter-Material -----/Y_______________________.__-_.__._ �/ -----/C7 i . " Distance to nearest.. Well ____�______________ Foundation -__.________ Property Line --___-_� _._____� SEEPAGE PIT [ ] Depth _--_ �- Diameter 1_1`-Y-- Number ___._._- __ Rock Filled Yes 'M>-"No 0' • Water Table Depth '--------60---------------------------------Rock Sire -----/-'ice------------------- Distance to nearest: Wel! --------e 'P_P--------------------foundation -/d------------ Prop.-Line ---- --_._.._...__.- REPAIR/ADDITIOM(Prev. Sanitation Permit#------------------------------------------- - Date -----__---------------------.-.___} Septic Tank (Specify Requirements) ---------------t `----------------------------------------------------------------------------------• - ` ----------------------------- -------------------------------f r--------------- -------- -------------------- ----------------------------Disposal Field (Specify Requirements) ----- ------------ -- ------------- _ {Draw existing and required addition on reverse side) I hereby certify that I have prepared this application sand that the work will be done in accordance with San Joaquin'^`j 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 "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*mef ubject to Workma ''% Compensati laws of California." Signed 41�_ it/_�---^—`--------- r- -- Owner . BYPv �. - Title �(Iio4her than owner) + " �-�-- i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------------------------------------------------------- DATE __.IC�_"Z' _`-� - !` BUILDINGPERMIT ISSUED -------------------------------------- --------------------------"------ --------------------------------DATE ------------------------------------------' ADDITIONALCOMMENTS ------------------ ------------------------- - ------------------------------ --------- ---------------------------------------=------------------ 4 i Y)-:-_:- - - -N;�� - ---- ------------------------------------------------------------------------- ---------- ----- --- --------------------------------------------Final Inspec i }m --- --------- ------ Date " SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M.