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FOR OFFICE USE: 'APPLICATION ICOR SANITATION PERMIT ................. :----- ,7S= J' Permit No. ..--------------•---• (Complete in Triplicate) . ........ . ...... This Permit Expires 1 Year From Date Issued Date Issued 1 .. _9..: r 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 Oricliapance No. 544 Wand existing Rules and Regulations: - JOB ADDRESS/LOCATION .. C 3- .. ENSUS T ..... _ .......0 TRACT Owner's Name O./kms-�j A- - .... ......................:.................. ....:................Phone .3r��...�..._......C�.7 ! Address .--�p�,. .J��$""-�_..... .....1...: 9 - . City .......- i _ - Contractor's Name ---- _ ...... _-_ . .. ............License # Phone -::. 'g. Installation will serve: Residence Apartment House❑ Commercial❑Trailer Court ❑ Motel ❑Other............................................ Number of living units:___ _____- Number of be rooms ...,.....Garbage Grinder ..-*VC)Lot Size .65V6A '..! ........:.......... Water Supply: Public System and name ...._...................._.....-----..........................................Private ❑ �. Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ t Hardpan jj Adobe 0 Fill Material ............ If yes,type................ ............ (Plot plan, showing size of lot, Iocation of system In relation to wells, buildings, etc. must be placed on reverse side.) r NEW INSTALLATION: (No septictankor seepage .pit .permitted If public sewer is available within 200 feet,) PACKAGE TREATMENT j ] SEPTIC TANK I ] g� Size................................................ Liquid Depth .........................V Capacity Y;� C_a_- Type r..*1 rQ4A.rMaterial..0 Afteft .. No. Compartments --+ i Distance to nearest: Well ..�1?�".........................Foundation .A.A........... Prop. Line ...Rcy ........ LEACHING LINE [ j No. of lines ______ ______________ Length of each line------6_�7------------- Total length .._4 'D' Box ------- Type Filter Material .. ........:Depth .Filter Material ............................... Distance to nearest: Well ------7A------.... Foundation .. .............. Property Line .... <7........... SEEPAGE PIT E j Depth Diameter ._..._...`--#amber ........................:... ock Filled Yes ❑ No 0 Water Table Depth ---------!!.wrawrr=.....•----................Rock Size ............._.................. Distance to nearest: Well ... ---_-_._-_.--_--._-_-Foundation ._ Prop. Line .... REPAIR/ADDITION(Prev. Sanitation' Permit# -------------------------------------------- Date.............................. ..-..) , S Septic 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 Joaquin County Ordinances, State Laws, and Rules and )Regulations of the San Joaquin Local Health;District. Horne 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 any person in such manner as to become subject to Workman's Compensation laws of California." Signed t C�& . . - ----- - ------- - Own er - - - TBY -------- e (If other than owner)l EPARTMENT USE ONLY APPLICATION ACCEPTED BY _. ' DATE . /. - 3`-------` BUILDING PERMIT ISSUED ----------------- .........DATE ------.-------•----------. -•_.. - ADDITIONALCOMMENTS -------------------------------------------•------••----.......---•---•.-.....------------- __-._....--------..-........ ..------------:----- ....... ............. ............. •--. ....---.................. _.'..-.final Inspection by: �' '....•-.• _.�......... EIi 13 .24 1—E 8 Rev. 5M SAN JOAQU€N LOCAL HEALTH DISTRICT 8/7jJ 3M