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y,, , FOR OFFICE USE: ' APPLICATION FOR SANITATION�PE M ra , � - ---- --------- ------------------------ {-f 14. rPerms �T t No ZfG a in Triplicate) --- -' --- ------- ---- '(C mplete�' .Date Issued ----------------._- _ ------- This er;Wt Expires 1 Year From Date 1444.,., Application is hereby made .to the San Joaquin Local Health District for a permit to�rconstruct and install the work herein described.This application.is made in compltdr ce'with Caunty Ordinance-No:_549'and existing•Rules and_Regulations: Y f6B ADDRESS/LOCATI N ._ �y--------- ------ ------ --------------------------------- --- =-- CENSUS TRACT -------------------------- Owner's Name ---- Phone ------------------------------------ ----------------------- Address ----------- MV - -t--- -- ---- - - -'� ` , �. � ��__'_'_..'City --- --------------------------r:--------------- ------------ --. Confiractar's Name-" k «� - - _ -- ------ --- �- - .License #' 3 �!----Phone_ _ Installation will serve: Residence Apartment House[] Commercial ❑Trailer,Court i❑ Motel ❑Other - ------------------------------------------ Number of living units:-----1----- Number of bedrooms __s3_:----Garbage"Grinder ------- 'Lot Size __4-. - '` .----------- Water Supply: Public System and name --------------------------------- ---------------- -----------------------------------------------------------Private ln� Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam 2�` Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ._____.__._.___-_--_-____ - j {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 [ SEPTIC TANK�[� Size!6/22--- Liquid Depth __.___________,_____ Capacity f as _� Type I Material___ --'-- No. Compartments .�.------_________ Distance to nea st: Well /0p-`_ __ _._____Foundation __._..fid-________ Prop. Line ___�______________ _ -------- ----- ` LEACHING LINE [t( No. of Lines -----4--------------- Length of each line.....- --------------- 'Total Length -A --------.____________ `D' Box - ll` - Type Filter Material &------Depth Filter Material _,_ ------------------------------ Distance _,-___________ ______________Distance to nearest: Well ---AP40______----- Foundation -------/�Q------ -- Property Line ________________________ u SEEPAGE PIT [ ] Depth ------________------ Diameter _---______'_____ Number ---------.------------------ Rock Filled Yes ❑ : No i❑ r Water Table Depth --------- ----T --------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line _-__.___..______------ 1 REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _____-_.____________--------------) SepticTank (Specify Requirements) -------------------"----------------------------------------------------------------------------------------------•---------------------------- DisposalField (Specify Requirements] ------------------------------------------------------------------------------;------ ----------------------------------------------- ----------------------------------------------------- l� -------------------------------------------- -------------- l� ---------------------------- -------- ----------- ---------------------------------------------------------- --------------- ---------------------------- - -------------------- (Draw existing and 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: "I certify that in the performance of the work for which this piirhit1s issued,?I`shalt not employ any person in such manner as to become'subject to Workman's Compensation laws of,Colifornia." -L 3 { Signed �. Owner:" - - ----- ------------------------------------------- Byn� - Title -------- ------ -- ------- -------_ �-------- (If other than owner) OR .DEPARTMENT USE ONLY I' APPLICATION ACCEPTED BY -------------------------------- ------------------------ DATE _ j--y--G d'.. BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------- =-- -- --------DATE ----- ------------------------- ----------- iADDITIONAL COMMENTS -------------------------------------------------- ---------------------------------------------------------------------------- ------------------ -- ---------- ., --------------- ------- ------------------------- ---- ----- ----------------- ---- -------------- ------ l -- ----- -- s � Da e �- ' Final Inspection by 1` SAN`JOAQUIN .LPGAL• HEALTH DISTRICT I E. H, 9 1 ; 68 Rev'.;SM