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FOR OFFICE USE: r, APPLICATION FOR SANITATION PERMIT ..�: L........................ -..._.__. . ... ...� . . _. (Complete in Triplicate) Permit No. .......:...............................-.........-------. This Permit Expires 1 Year From Date Issued Date Issued 4; I Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This appiica ' ism de 1 ompliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATI N ..... ..Q ._-- v.�N1.. -+t+ --- .5, CENSUS TRACT ......................::.. Owner's Name i . ... ... . ..... ._. . . . ...........-._.. j - � -------.... Phone ..................... .. ...Address . . ........ Contractor's Name - - ----- ----.... City -------- ----------- ----•.----_----- ............................... -- .......... ------------ ------------:-- -•-_-------------License # Phone ..r'.��:.�57...._.... Installation will serve: t , Residence ❑ Apartment House❑ CommercialTrailer Court �] �sl3tGHcuSe�`p � Motel ❑Other Number of living units:..__.! Number of bedrooms -------- --_Garbage Grinder Lot Size ..� ... � 1.__.__..• Water Supply: Public System and name ._ � �C..- W __,. .............................. ..•---....- --•---.---------_ ........... Private ❑ Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ ( r Hardpan ❑ Adobe Fill Material If yes,type ........ ................... (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 public sewer is available within 200�feet,} PACKAGE TREATMENT [ j SEPTIC TANK Size---------------- ........... ._ .... Liquid Depth .-.--•- Capacity .��- �- . Type CDWIZ+ Ie Materiai..5i?t.f_C0;3C...... No. Compartments A— _._ Distance to nearest: Well �----_----- - _Foundation � � �$� b�.............. ...._.......----- - LEACHING LINE [ j No: of Lines Length of each lineFoution.., Prop. Line •-- ..---_ Total Length t__ --------------_.__ r� D''Box Type Fil tenial �or _Depth Filter Material •._.....� ....__.......----------- 1�� r Distance to nearest: Wel ..�.1./.�_____________ Foundation . . _..._..-.-....... Property line ..It..�T_.....__-. ....... I ; SEEPAGE PIT [ ) Depth Diameter ....... -..---- ---__--.-- Number ... .............. Rock Filled ;Yes [) No 0 Water Table Depth ---------------------------------- .............Rock Size ......___...... ... Distance to nearest: Well .................. ......... _-_-.----_---_-Foundation .---.... _ ------- Prop. Line ..='..:............•-_- p REPAIR/ADDITION(Prev. Sanitation Permit# --------.----........------------- ........ Date _..------------:---_._.- ) �}. Septic Tank (Specify Requirements) .... . .................. 1 ----...._...... Disposal Field (Specify Requirements) --------------- r - ........... .... .......................... . ... . i i (Draw existing and required addition on reverse side) I hereby certify that I have prepared this applications d tharthe�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 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 beco subject to I* on's ompensation-laws of Californici:"; `Signed t -- :... . . ..... i . ___ Owner r BY ....... -- .-•.. ... ........... Title . ... .............---- '... .._ ..._. (If other than owner) -- ��_�_�,�_ _ FOR DEPARTMENT USE ONLY . t APPLICATION ACCEPTED BY .-_ DATE ._. . ... _ i - - + BUILDING PERMIT ISSUED ._.. .. ....._..•• -- DAT£ . . ADDITIONAL COMMENTS ................. ............ ..•---.......:........_.... . -.----._- ------- ........ -•--.-- -.,-----......._....----_... 1 .........-- ---- .- ............ ...... ................ ......... ... ----..._- -..-- ------------------------ ..�`' Final Inspection by: -_-.-.Date ----��':.17-A �{.............. A J AQUIN LOCAL HEALTH DISTRICT a F u 1.3 24 1_-s-e o_.. C., _