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p 4 t FOR OFFICE USE: --------- ------------ - APPLICATION FOR SANITATION PERMIT - - -------------- ---- - (Complete in Triplicate) Permit No. ---------------------------- ------------------------------ This Permit Expires 1 Year From Date Issued Date Issued -14- 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: .� 3d2a U G ARoe/u AUSJOB ADDRESS/LOCATION - - ----------------------------------------------------- ----------------- -------CENSUS TRACT ----- Owner's Name --------FN ------ -------------------------------------- --- -- Phone Address - -----�_$ �---------- fi/n pok-f- WAY >7I----ltV+ - - City ----------------------------------------- Contractor's Contractor's Name - ------- tK-----------------------License 02Phone --------------- Installation will serve: Residence partment House-E] Commerciah❑Trailer Court i❑ Motel ❑Other Number of living units_____________ Number of bedrooms _�-Garbage Grinder Al . Lot Size ---- Water -Water Supply: Public System and name ------------------------•_-------_ _______Private --.----------------------------------------------------------------- - Character of soil to a depth of 3 feet: SandSilt❑ Clay ❑ Peat❑ Sandy Loom •❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill,Material -------- --- If yes, type ---------------------------- (Plot -_______________________ _(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) Lrl NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Q PACKAGE TREATMENT ` [ ] t 5EPT1C TAMC'[] Size_--_------ -- �J } x --------------- - --------- --- Liquid Depth --------------- 1. Capacity p Y ------------ TY --------------.Material------------- -------- o. Compartments d Distance to nearest: Wel ---------Foundation ------- -------------- Prop. Line -------------•-------- LEACHING LINE [ J No, of Lines -------------------- --- Length of/each line---------------------------- Total Length --------------- 'D' Box ------------ Type Filt r'-Material,______ __ = Depth Filter Ma erial __--_ ----- ---- --------------- -- Distance-to nearest: WeFf __ -'-------'Foundation-___�-------- Property Line --------------- -------- - SEEPAGE PIT [ 1 Depth ---------------- -- Dia eter r_____________-- Number -----------------_----- --. Rock Filled Yes E-] NoC]Pth 1�-- Rock Size ---------- -- Di tante to�neaeest: Well -------------------- ------•----------._Foundation _-__ - ----- ----- Prop. Line ---------------------. REPAIR/ADDITION(Prev. Sanitation Permit# ___-__ Date _________________ ) i� Septic Tank (Specify Requirements) ----------------- Disposal Field (Specify_R i_uRrements') _ - - _-_9X_15`"1-9E.- s�"j1 � K -. �A.�'',------C'of1�Cj�>�r�---- P € f �3. ------PV5iTl----RAX__" --------4Z --f�-qI.--r---- 1c� _ �nr ----------------- -- 1 �= -------------= ---- .: ----------------------------------------- raw 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: 0 t` W 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`fio Workman's Compensation laws of California." Signed _. --� - ---------- '---- _ Owner BY ----------- --------------------------r ' --- ed Title -------- --- ----- --{If other than own y FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- - -- -- -------- --t n`--�--------------------------------------------. DATE ---- - - -- - - - ------ ------ BUILDING PERMIT ISSUED --------- -----DATE -------- ---- ------------------ ADDITIONAL COMMENTS -___ _ - ------- ------------------------- -------------------------------------------- -- -------- -------------------------------------- ---------- - — - —_ _ - -- Final Inspection {-- - -- �-- - -- ---- ------ ----- - - -------------- - -- ----- --- `------•--------------Date _..�-----r-`---� ------ - ---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b$ Rev. 5M