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FOR OFFICE USE: APPLICATION FOR l SANITATION P!cif Permit ------------------ ---------------- --------------------- (Complete in Triplicate) ----- -------------------------------------------------- Date Issued _ 3-'--- ---�z --- ---------------------- This Permit Expires 1 Year From 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: 1�-.g -.c - - -- ---------L��a"u-��-+_�'�,-.c� _ •/� `?�.Q-�-.C'�CENSUS TRACT _..----------------------- JOB ADDRESS/LOCJA�TION ._ .---------Phone ------------------------------------ y Owner's Name -W ----------------- -- ------------------- .............................- - . - ----------- City v -------------------------- Address ----- =� �-'-� ---------- - -----• ---------- -- -- �g_ T 7._ --------------------------License # _/ g.3 3------ Phone ---------------------•-------- .4 Contractor's Name _.____Cn"-*---°-� = Installation will serve. Residence X Apartment Hous e❑ Commercial: Trailer Court ,❑ Motel ❑ Other -------------------------------------------- Number -------------`-----------------------------Number of living units------ _----- Number of bedrooms ____:___Garbage Grinder ------------ Lot Size -------------------------------------------- -------- Private , Water Supply: Public System and name ------------------ ---•--- ----- ---------------------- ---- --------- -------•- Character of soil to a depth of 3 feet: Sand❑ • Silt❑ Clay ❑ Peat❑ Sandy Loam it Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ---------------------------- {Plot plan, showing size of lot, location of system j 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,) Li PACKAGE TREATMENT [ ] SEPTIC TANK�[.] ' Size------------------------------------------------ Liquid Depth P ------------------ ------ Cal5acity Type ---'I---------- - ____ Material---------------------- No. Compartments ---_---------------•- tDistance to nearest. Well ------- _ ---- ------Foundation -----_----------- --- Prop. Line ---------------------- Total Len th :--------------------------------- LEACHING LINE [ ] No. of Lines ______________ ________ Length of each line___________-_____.._ ___ g r ____De Depth Filter Material - t 'D' Box.-------- - Type Filter Material -------------------- P ---------------------•----------•---------- ---- Foundation --- Property Line -------------- ---= . , Distance to nearest: Well��'________________ ----- ---------- - �- .. Rock Filled Yes ❑ No SEEPAGE PIT [ ] Depth _ Diameter. ---------- =--- Number ------------------- -- - ------------------- I Water Table Depth ----------------5`'' Rock Size ------------- - � Distance to nearest: Well ___________________ _ -------------------Foundation --------------- ---- Prop. Line -------------_----_- i _... ` S__ ---------- Date ------------------------•---------} .� I REPAIR/ADDITION(Prev. Sanitation Permit# """- ----- - 1 --------------------------------- -------------•-----------.. Septic Tank (Specify Requirements) _I�-`-_______-" --------------------------------------------------------------- Disposal Field (SpecifyRequirements) ' R / - -------- ---- - and - - (Draw existing 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: "1 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 subject to Workman's Compensation laws of California." Signed '� -�_ �. _ _: - -- -- -- vcrn a. - {{\\ By ---- --------------------------------------- -- "n_lts-g—�zL. '-- ----- - -=-- ---- Title __te6'�- --:�r�crt---- --------- ---------- - (If other than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------ DATE __ ---- - -- - --------- -- ----------- _DAT -------- ---------- - ------ ------------- BUILDING PERMIT ISSUED ------------------------- --------------` -- "---- ADDITIONAL COMMENTS ----------------------- ---------------------------- ------------------------------------------------------------------------------------------ - - --------- -- --- - _ Dater� ." y f.. ---- -- -- -- I Final Inspection b - SAN JOAQUIN LOCAL HEALTH DISTRICT Ll n , •s.a De KAA