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t. FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ..._..»......................................... (Complete in Triplicate) Permit No: --- ........... This Permit Expires 1 Year From Date Issued Date Issued _.f Z_J6.: pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application A;�rt�adoe in compl ce with County Or once No. 54 and existing Rules and Regulations: JOB ADDRESS/LOCATI - . CENSUS TRACT ...................fit Owner's Name ---•-•- -- O ...........•-----Phone 79T4 L Address - -611 -f-$- .. ..._...... - _City ----- _•..------- ---------•---._.._.._- Contractor's Name---- ......... ---- ..........license / P �!_.. Phone ?�-��1- Installation will serve: Residence❑Apartment Houseo Commercial❑Trailer Court j] Motel ❑Other.. - ............................... Number of living units_____________ Number of bedrooms _._._.___Garbage Grinder ------------ Lot Size .......__._......_.._-_---------.-..._- Water Supply: Public System and name ---__._---._-t...........—.-.-___________.______..—_ .._.__..____..__._._._..: ____.Private Character of soil to a depth of 3 feet: Sand j] Silt❑ Clay ❑ Peat❑ . Sandy Loam(X Clay Loam g Hardpan❑ Adobe 0 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,) �r N Ci r i PACKAGE TREATMENT [ ] SEPTIC TANK;jQ ize.._.__+ll�C+.� � �.......:...... ..... Liquid Depth Ca aci T - ' MaterialS.Prr_`---- No. Compartments i Distance to nearest: Well Foundation .....AO.0_-P__ Prop. Line LEACHING LINE to No. of Lines ... ----•--- Length of each//Aine-----:.��_--r__..---. Total Length (� 'D' Box __. _. Type Filter Material _ &C:;k,...Depth Filter Material .._f8. Distance to nearest: Well ------ ... Foundation --------L6" ___ Property Line_ SEEPAGE PIT [ ] Depth ------------------- Diameter .—._. ._._._ Number --------.---------_.....- Rock Filled Yes ❑ No .a y _ Water Table Depth - -----__.—.._....._--_...—__._..Rock Size ................ t Distance to nearest: Well _ __.._--.--_.._............Foundation ._.___._.__... Prop. Line — REPAIR/ADDITION(Prev. Sanitation Permit#_._.._..._.._.__._____............__ Date ....... SepticTank (Specify Requirements) .............................--_-..._............_._.___..........—____.v__._-._._---.....--.-._..—_.._..... Disposal Field (Specify Requirements) .................._....—._..-_.._......—_•.-.-- ------...--------------- ----------------------------------------------- -------------------------------------------------------------------« ..._.......---------—--------------------......................_............................. (Draw existing and required addition on reverse side) I hereby certify that 1 hpve prepared this application and that the work wilt 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, 1 shall not employ any person in such manner as to become subject to Workman's,Compensation laws of Califomic." Signed ------��--�-�- --• - -- -:--- - --- .: ..—--------------------- Owner 4- By•.............. ...' -� ? _ -—-- ______..._ Title -- '.... ........ - _ (If er than owner) //nn FOR DEPARTMENT USE ONLY 4PPLICATION ACCEPTED BY - AZI = u - ------- .............................. DATE -� -/`-� ----------- --- '11LDING PERMIT ISSUED ----..._._...___.____....-_----.._.____._-._---............._.____..__.--.---_DATE ....................................... DITIONAL COMMENTS ..._...._.............. -'----.._.---.._—---------......_......T__...._....... .............-............................ ...............--.........................................................—...-.....,...._.....--................._-•-•--...___- _.... - -- - — - - -- - —_ ._._.. -- _ oection by: _._._.... r-.. ...-......-...._.._ ------------------------Date ......._....... -....._.._. SAN JOAQUIN LOCAL HEALTH DISTRICT