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c � FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT -- 1111��------------- A In------- S [Complete in Triplicate) Permit No. �_. .r---_5 ` -AN . - �` Date Issued --- ------------------------------------- - -- _ _________ --This- -^ _ Permit Expires -- — 1Year From Date I -� ssued - Application is hereby made to the SanJoaquin Local Health�Dis-77ict`for a perm_it`'to construct'and-iristall the-work herein described. This application is made in.compliarice with.County.Ordinance, l�[0. 'S49 and existing Rules and Regulations: - JOB ADDRESS/LOCATION �/g6.-------A/A _Tlv-.___ -------�� _CI NSUS TRACT ---- - r - . Owner's Name---------- -- -�Y__M��Y!'----------��A7-d 11��- ---------------- ----------Phone r - Address --- - -1 ------ ,C•it vZaCiC-7'n'-V--------------------- -•------ Contractor's Name --- -----•----------------------- ------------------------------------.License # ---------:-------------- Phone . -y---- •----- Installation will serve: Residence ❑Apartment.House,❑,Cor;irnercial ❑Trailer Court ,❑ i 1 Motel j rOther --- '1� - ----ff®Nj�t_ "f�� . r ,�J117 e : Number of living units.---./----- Number of bedrooms ____?____Garbage Grinder ------------ Lot Size -------- -7__ --C.. Water Supply: Public System and name --------- ------------------------------------------Private ❑ t _ . Character of soil to a depth of 3 feet: Sand'E] Silt❑ Clay ❑ }.'.Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe [] 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,j PACKAGE TREATMENT SEPTIC TANK'[ ]'" Size-_r :QjR------(E1-4 _____________ Liquid Depth -------------------------- Capacity ---C0?-OQ---I9.ype Material-Q.6e%1-•HF x-<No. Compartments Distance to nearest: Well -------/__-/-0_f_______________Foundation ------/a -0____-- Prop. Line ____ ___5________ 4 LEACHING LINE VkIN—o, of Lines ------ ?�______ Length of each line----/ ------------ Total Length �/T e Filter Material D' Box -- yp f or Filter Material _____- �' -----------•------------- Distance to nearest: Well ------13.0-------- Foundation ------r'91-�___._____ Property Line _.-_1r----______-____ SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No Water Table Depth ------------------------------------------------Rock Size ----------------------------•--- Distance to nearest: Well ------------------------------------ Foundation --------------- ---- Prop. Line -------------,-•-.__-• REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- Septi Tank (Specify Requirements) ------------------------- -------------------------------------------------------------------------------------- Disposal Field (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 Joagv/ County Ordinances, State Laws, and Rules and Regulations-of the San Joaquin Local Health District. Home owner or licen li'°T 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 War man's Compensation laws of California." Signed -------- ------------------------ - Owner BY ----------- -------------- ------------ --- --------------- ---------------- -- --------- Title -------------------- (If other than owner) _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- - -- -`-- ------------ -� - --------------------------------------------- DATE _: -7BUILDING PERMIT ISSUED --------------- --------------------------------- _ --------------DATE ---- ------------ - ---------' ADDITIONAL COMMENTS . ---------------------------- ---------------------------------- ----------- � ----------------------------------- - ---------- -- ----- ------------------------------------------------------------------------------------------------------------------------------ = -------------------- -------------------- ---- -- --------------------------------------------- ----------------------------- ---- ----------------------- Final Inspection by: --------- Date ---�r-1_?Y o-- --� �JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.