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i! FOR OFFICE USE: ' APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. -. -- - -- ----- This Permit Expires i Year From Date Issued Date Issued __� _ = ------- 7J 1 y 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 ----- � -- -- ----------------- ------------------CEN SUS TRACT ----- ----- ------------- Owner's Name QL4 _ Phone - ----------- - _ --•------- Address { L7- -------------------------- Cit Contractor's Name ------ --- - _ SQ`7T f- ------.License # /��/r----- ----- ---------- --- _ Phone ------- -- Installation will serve: Residence %]Apartment House-E] Commercial ETrailer Court ❑ Motel ❑Other ------------------------- Number of liv ng units------(__-- Number of bedrooms ---�__Garba a Grinder -_ - �.- � Gd -------- tot Size --� �_�.�------------ - •- Water Supply: Public System and name --------------------------------- Private ❑ .r. -----"------••---- - Character of soil to a depth of 3 feet... ❑ .: Sand'[]. and' Silt, Clau. _ � t 4 [] . Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam :❑ Hardpan ❑ Adobe bC Fill Material ------------If yes, type _________ _______ --------- (Plot plan, showing size of lot, location of s +y ' ystem in relation to wells, buildings, etc. must be placed on reverse side.)' NEW INSTALLATION: (No septic tank or-seepage pit-permitted f public-sewer is available ��itliin 200 feet,] PACKAGE TREATOr MENT { ] SEPTIC TANKf�I y � •�+`�{itSize-_ _- ��_ __ � _ 1` Ie' e �'._ ---------------- -------- Liquid Depth --------------------------- Capacity ---------- TYPe Materia -t No. Compartments Distance to nearest: Well --------_" - -- --- ---- ----------Foundation ---------------------- Prop. Line -----------.-_-------- LEACHING LINENo. I I L ] of Lines ------------------------ Length of each line-------------#---------- )� _ Total Length -- - ------•----•-•--------- 5 'D' Box ------------- Type Filter Material _ _ - + _Depth Filter Material __.-__ ._ Distance #a'inearest:,Well t ------------- Foundation ---------------- `t.Property Line ------ SEEPAGE PIT [ ] Depth Diameter ----------------- Number -----------%---------------- Rock Filled Yes ❑ No Water TableDepth ----#--------------------------------------------Rock Size ----------------------- Distance to nearest: Well -------------------------------------- lFoundation _---_._--_-"---..__ Prop. Line _..---------_,_-• -_-- ' REPAIR/ADDITION(Prev. Sanitation Permit# _--7777 '„�. ., - - ' Date -------i ) Septic Tank (Specify Requirements) ----------------------- --------------------------------_____ -- - -- Disposal Field (Specify Requirements) ______________ ____•-•- 1 -------------------- --------------- s #" '`� t -,}C� i { ------ -------- ._.-" ----------------- '_---------------------------------- ------------ --- ,i,,(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 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, I shall not employ an as to become subject to Workman's Compensation laws of California." P y Y person in such manner Signed ---------------- -------------- Owner --------- - --------- ---------------------- By --------------- -------- -- ------ - -� ----------------------------- Title f (If of er t owner ----------------------------------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ---- BUILDING C� Y �'--------- PERMIT ISSUED _____ _ __ E - --------------- DATE _T ADDITIONAL COMMENTS -------_-----_ _"" "" -- 77 DATE --- -----•---- ------=•-�-----•-�--------- --------------------------------------------------------------------- --------------------------------•------------------- ------------------------------------ ---------------------- ------------------------------------------------------- ---------------------------------------- -------- --- -- Final Inspection b ""- " ""------- ---------- --------------- Y --------------------- -----.Date _ � - / ----- ------------------------------------- - SAN J -AQUIN LOCAL HEALTH DISTRICT 1 I E. H. 9 1-'6$ Rev, 5M I