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r� FOR OFFICE iUSE: APPLICATION FOR SANITATION PERMIT ----- ------------- - - - � y_. (Complete in Triplicate) Permit No:'6��0_�P ---------=----------------------------------------------- ____ _________________-_______________________ This Permit Expires 1 Year From Date Issued Date Issued �a a1: 9 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. JOB ADDRESS/LOCATION __. _ -------- Owner's -- / I3� �� A_CTA-L F1----------------------------------CENSUS TRACT ----- Owner's Name --- -�L-------- ViQQbs_C&J--- ---------- Phone Address --------/91.�.-�-----S--------- WP-4T-N F ------------------------- City - -----F?)__f>Q-tQ--------------------------' Contractor's Name -- ..... 4---- 14R � -----------------------------------License'# - - E- ----- Phone '_ 2�. -_ T Installation will serve: Residence partment House❑ Commercial :❑Trailer Court El Motel ❑Other -------------------------- Number ------------- ---------Number of living units:_-____ ____ Number of bedrooms _ g 1 � �______Garba e Grinder ______'_'_'_ Lot Size Water Supply: Public System and name --------------------------------------------------------------- ------------------------------------------------Private Character of soil to a depth,.of 3 feet_. Sand'[ Silt[_;- Clay ❑ Peat❑ Sandy loam Clay Loam;❑ __� .�.. - 4 Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type H es a __.-------____-- '-- (Plot plan, showing size of lot, location of system inrelation to wells, buildings, etc. must be placed on reverse side.) �1 NEW INSTALLATION: (No septic tar')k or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ]--SEPTIC-WANK:[ Size---- q p ___ _ - -- �-��--�----��---- -,-- Liquid Depth __ Capacity -f �- _ Type )'OEM3 Material-_CVAAC------ No. Compartments __'^ -------- Distance to nearest: Well ..........4T_V------------------Foundation ---------- Prop. Line ___S . - LEACHING LINE' [ ] No.`of=tiness-_-_ _______________ Length of each line------ _-_� _ __.-----_ Total Length. ----- ----------- - i Z S . 'D Box AID -__ Type Filter Material RQCY-5x-----Depth Filter Material ------- _..`._______________________ # .. __-_---_ Foundation ___ Property Line ------------------- SEEPAGE __. __ r Distance'to nearest: Well --------------- ---_-------_---_-__-- _ - -----------:__-- SEEPAGE PIT [ ] Depth i I• _ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock ^ Size -------------------------------- -Founation -------------------- Prop. Lin$Distance to nearest: Well --------------------------------------- , _-------- REPAIR/ADDITION{Prev. Sanitation Permit# --------------------------------------------- Date ---------------------------------_) SepticTank (Specify Requirements) ---- --- --------------------------- -------------- -- -------------------------------------------------•- ;----------------------- Disposal Field (Specify ,Requirements) ------Foo-------L0_fDfk190.M--.......f_---tr19-'i4-)------- -D 7�.- - - ------------- :7 __ _� ----- -- ----------- -- i I existing required reverse side) 1 hereby certify that 1 havelre aTed this appation and thatorkrwill be done in accordance with San Joaquin 3 County Ordinances, State Idws, a'nd Rules and Regulations of the San Joaquin,Local Health District. Homeowner 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 I as to become subject to orkma `'Compensation faws-of-Califotnia." �, - Signed ______ __ _________ Owner BY t---- --��-- -- ---------------- ------ ------ Title -------------------------------------------------- 1 (If other t an%weer) �. f FOR DEPARTMENT USE ONLY APPLICATI ^ �-.-,'---_:-----------------------------7`'-"-,—=--------_--�__ -:--.------------DATE BUILDNGOPERMITCISSUEED -� h=_::� - -- '--------------------------------------------------------DATE`- , ------------- ADDITIONALCOMMENTS - ------- --------+w: -- -------------------------------------------------- --------------J---- --- --------------------------- ------------------------- ------ -------------------- -- ------ -- --- -----------------------------------------------'-------------------------------------- - ------------- - ------- --- -------------------- - ---- -------- ----- -- - -------------------------------------------------------------------------------------------- --- Final Inspec 'on by: _ - -- -------- ------- ---- - - -- -- --- -- -----------------------------------Dafie SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 7-'b8 Rev. 5M j