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' :FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT pTriplicate) {Coen fete In Kermit No. ............... ..... i ...................... . ....... This Permit Expires 1 Year Front Date Issued Date Issued .-�,A..._�._...._.. 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: i JOB ADDRESS/LOCATION .I. a .__.-r/ Y� ...r _..!![' � � ...................... ...-..._......... Ar-15A y� /� l ....CENSUS TRACT ......... Owner's Name Ar-15..._.:.--�------ /2 �[. ....r .........................Phone -.............--...........�... Address . .��.�3---._ . G..e-76,cy� f .,...._-•---•_ ............. City G.a.t� B.Cd......... -•--- , 41 Q... Phone >�1.91:. Contractor's Name/�--��__._--��ic,.-••.-��-vl.�-S:.,--....---.license 9f-` �.7�.�C7. _ _... 91..0 Installation will,serve: Residence❑Apartment House 0 Commercial❑Trailer Court Motel ❑Other ..�!L2-----V Number of living units:,,rO�Number of bedrooms _-'x.t5!�'.�Garbage Grinder ..-01r Lot Size ...... .....:.......: Water Supply: Public System and name .............................................................................................................Private , Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑. Gay Loam ❑ Hardpan❑ Adobe 0 Fill Material ............ ff 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,) PACKAGE TREATMENT [ I SEPTIC TANK f ] size........4f_ z-Q---,!4.-........... Liquid Depth ---•-�P�...:. .. Capacity -'-5 �-------- Type ��!e 9E,sr MaterialNo. Compartments _J...4....:... _ : .... Distance.tdlnearest: Well -__- :J____•-•----...-•-.. ...Foundation .............. Prop. Line ---,..:'....... Q!� F d ..._...�J LEACHING LINE [ ] No. of Lines .._ .._.. _ g - --•-- ----- Length of each I�ne_...__.�.'Q.............. Total length ---c�_.......-..... .. . 'D' Box .._I ----- Type Filter Material f ...............Depth Fitter Material .._..`.: .......... ..... .. ..---. . Distance to nearest; Well ...... Foundation ----------- ... Property Line ... g........: SEEPAGE PIT [ J Depth .......:_!_.._..._... Diameter ________________ Number __._... ------------------- Rock Filled YesNo Water Tablet ❑ ❑'" ' . Depth ..-......--•---------------------•--•--...-----hock Size ....-------------.....---...._.. i Distance to nearest: Well ________________________________________Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prov. Sanitation Permit# ________..._._.-_.- ------ Date __________________________________) Septic Tank (Specify Requirements) --------------- ................................................... --------• _-•----..... _..........: Disposal Field (Specify Requirements) ___________________ _ ----------------- ---------------------.... .-- f ------------------ --------------------------------- ............. . --------•--•-----------------------------------------•---•-------••- ------------------------•-------------_------------------._......................................................................... . (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, Nonse owner or Ikon. 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 ------ ) --------- Title ----------------- I Ilf other than owner FO DEPARTMENT USE ONLY a APPLICATION ACCEPTED BY .. 7J------•--- DATEf-' . NG -PERMIT ISSUED --------------------- -------- -------.........................------------------------- ............DATE...._....._...... ..... -------------------- ADDITIONAL COMMENTS . ..........----------------- ---------------•------.-------------- ------------------ ------------ ------------.----------------------------------------- ...-----•----.....---•-----------•----•-- ------ ------------------------ •. •----••------- ------ • •- - -- • --------•- P y: ......................... - 2X- --.1 ' Ina Inspection b ..._..._Date ---- _. ..... ................ .. 2a � v• SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M