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.FOR OFFICE USE: - ---------- _ �,PPLICATION FOR SANITATION PEWS" i {Complete in Triplicate) ---------------------------- ----------- iii- This Permit Expires 1 Year From Date Issued 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: f �t JOB ADDRESS/LOCATION . /L` S- '/�;'!-�`_n+ r .£ ---- .._.--CENSUS TRACT ----------------------- r� Ste_ Z Owner's Name __.._.1711;'.7_a.Et,;'y---------�tI '- _ !Y --------------------- ---------Phone 7`f_' -._ ---------------------- ----- ' -------- ----------Phone------------------------�- Address --_...f�-�-�--�---�`-�--- �-- ---�.!_1�1`1_�1��-- ---etY -��J� '�� Contractor's Name ---------(55�-!J?�[.-'`= r- ------------ _ ._ License # ---------------- -- -�----------- �� F Installation will serve: Residence 2_X`partment House-❑ Commercial❑Trailee Court Motel ❑Other ---f.9TH!kG"_ _V"Ltf IN& M14 C N r 6 i t= Number of living units:.-------i--- Number of bedrooms ----f,>`----Garbage Grinder --bi-,J--- Lot Size -------14 _____________ �i Water Supply: Public System and name -------------- --- --------------------------------------- -------------------------------------- --------Private 4 Character of soil to a depth of 3 feet: Sand')V Silt❑ Gay ❑ Peat ❑ {{Sandy Loam '❑ Clay Loam:❑ Hardpan ❑ Adobe ❑ Fill Material --- f.,`_ If yes, type ---------------------------- (Plat 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 J ) Size------------------------------------- ------ -- Liquid Depth -------------------------- Q\ Capacity ------------------ Type -------------------- Material--------------- ------ No. Compartments ---------------------- Distance -------------------Distance to nearest: Well -----------------------------------Foundation ---------------------- Pl•op. line ----_--------:------•- t LEACHING LINE [3 j' No. of Lines ------------------------ Length of each line;--- ---'------------------- Total length -.---,----------------------- Q 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ------------_--- __,.:-------------------_-_ Distance to nearest. Well ------------------------ Foundation ------------------------ Property Line ------------------------- SEEPAGE ______________-:___SEEPAGE PIT [ } Depth -------------------- Diameter------------------- Number _------------------ Rock Filled Yes '❑ No C] Water Table Depth --------------------------------------------------- Size --------------------7------ ----- Distance to nearest: Well .------------------------------------- -Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ---------------.----- -- Date ---------------------------------- Septic ---------------------------------Se tic Tank (Specify Requirements) _ { Disposal Field (Specify Requirements) --ADD----- �f l ------ f � --I- --------------- - - -- 6 ---- ----- .... -R --------------- ------ a-. !F _ - r --- --------- . (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 i 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: "1certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner ias to become subject to Workman's Compensation laws of California." Signed --------------------/----- r - ------------- ----------r----------------------------------- Owner BY -------------------------- -Title ---- ------- ---- ---------- ------------------------ ------------ ' (if other than owners FOR DEPARTMENT USE ONLY f BUILDING PERMIT ISSUED _-------------------------------- ------- -------=------ ----- ------------------------- -------------DATE ---------------�-:�------- ------- APPLICATION ACCEPTED BY - - ---------- DATE ---- -- ADDITIONALCOMMENTS - ---- --- -- --- ------------r---- ---- ------------------------------------------ --------------------------- ------------- ------ ---------------- -- --- - -------------- --- -- f` ---------- - ------ ----- ---- --- - - ---------- -- ` -- - --------------------------- ------- ---------------- --------- 1 - -- ----:: _ - -------- -------------- ---------- FinI inspe ._ ` --------------------- --- Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H, 9 1-`6ja ReV. 5i4rt