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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------------------------- Permit No �_q 4y . [Complete in Triplicate) ------------ This Permit Expires T Year From Date Issued i Date Issued--------------- Application is hereby made to the San Joaquin Local Healfh"District for a permit to construct and install the work herein 1 described. This application is ipade in compliance with County, Ordinance No. 5.49 and existing Rules and Regulations: Al- gr¢Wt—40- . 'l�- JOB ADDRESS/L 71 Jj --1°-df`l�¢- ' -------------CENSUS TRACT _-_----------------------- ----- - ,. t Owner's Name - 1' -�' -- ------ ' Phone Address -- ---- P J City _-------- ---------- ------------------------------ y' 1 --- -------.License # 775_3-7--- Phone Contractor's Name _ _______________ ______ _____ Installation will serve: Residence partment House°[f-Corrtme-rciah[]Trailer Courf i❑ } Motel ❑Other ------------------------------------------ �/ Number of living units:---___ _____ Number of bedrooms _______Garbage Grinder -_ Lot Size ._ -P___X_33� ------- Water Supply: Public System and name ------------------------------- ---------------------------------•--------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑,,,, MMSandy Loam ❑ Clay Loam ❑ Hardpan E] Adobe ill Material _�'!�°-f� 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 seepa it permitted if public sewer is available within d20D0 flet,) p PACKAGE TREATMENT { ] SEPTIC TANK'[ Size____________ _ __X__ ___ q Capacity _-__k-- -- Type -- -a-katerial--- No.lCompartrrients ...........-........ -- Distance to nearest: Well ___ _____________________Foundation -0 / Prop. Line .......... ..+ LEACHING LINE No. of Lines __ --.---'-Length of each line__ �_ (� -- Total Length .___ -- 'D' Box --- � Type Filter Maternal ' ___Depth Filter Material ___ _ ___:_________________________•---- -- ------ ----- -Distance to earest: Well-_-___�!�_/Foundation .__�_. ___t_._------- Property Line _............:_.. SEEPAGE PIT Depth - ------- Diam ter' - '4- Rock Filled Yes lb a f ________ Number _.__. Water Table Depth ----- -----------------------------------Rock Size F IL,. ---------- rr T t Distance to nearest: Well '.__ __--__/-_CV.................Foundation __-__��_�____ Prop. Line ........ j REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------.------------.---) Septic Tank (Specify Requirements) ----------------------------- '-------------------------------------------------- -------------------------- ------ DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------- (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 Sart Joaquin Local Health District. Home owner or lice 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 as to become subject to Workman's Compensation laws of California." Signed --------------------------- -------- Owner BY ------------- ------------------ --�'�1� Title --------------------------- -- --- ---- ---------------------- --------------------------------------------- (If other tha ow r) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- -- ------------ - ------------ ---------- ---- DATE -----.7_1-_ -. BUILDINGPERMIT ISSUED -------------------- ---- -------------- ---------------:------------ DATE ------------------------------------------- ADDITIONALCOMMENTS ------------------------------------------------------------------------------------- ---------- ---------------- ------------------------------------- - --- ---- --- ---- ----- ---------------- ----- ---- ------ ------- - ----------- --- ------------ ----------------------------------------------------- -- ------ - --- - Final Inspection by: -= ---- Date SAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M