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rUK UFFICE USE: ------ APPLICATION FOR SANITATION PERMIT wY {Complete In Triplicate) Permit No. ... 5 o2.To ......................................................... This Permit Expires 1 Year From Date Issued Date Issued .. QST.Z� 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 Regulatlons; JOB ADDRESS/LOCATI -N .-4,-,. �-�°fl --�s ?&r� ��-,✓ CENSUS TRACT ......... Owner's Name _ ..._.. .-_... .....p...- ••...... ...... Address ........................ .., . ..... .. .......... �"7''�-7. s...` . Phone � .. City ... fir . Contractor's Name __..� . .._........ �c.c.e�� ....License #c�219 �1.... Phonerr.. Installation will serve: Rei �'-------... �.� Residence J4 Apartment Housef] Commercial[]Trailer Court C] Motel ❑Other Number of living units:._._.._...-. Number of bedrooms .._��..------Garbage Grinder ............ Lot Size .......c�'..r�� Water Su ............... . ........Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silto Clay O Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe W 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.l NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,l PACKAGE TREATMENT [ ] SEPTIC TANK �[y � ] Size...--------- ---T./.3.�I-Y��•�,'•..... Liquid depth .... Capacity p ty _10�_741 Type �.. Ma#erial.._�{�-- No. Compartments 2 J ...................... CSI Distance. to nearest: Well ----,•---------_------- ..........Foundation _.�� . ...� Prop. Line .. r � o. LEACHING LINE [ ] No. of Lines _..._..�_..---_--- Length of each line.._.......7,�` r Total Length /•4�27_ J ... .. ..._.. 'D' Box ---- Type Filter Material 514t't-- A-Depth Filter Material __191m.................... Distance to neatest: Well ........................ Foundation ..Ja '!.._...... Property Line SEEPAGE PIT ( ] Depth ._��- ---'... Diameter :+--j�._ Number ..._.__ ' .......Z, Rack Fitted Yes ,�' No ❑ IE Water Table Depth ..-------- f Rock Size ._... Distance to nearest: Well ...................................... Founda on Q i .6 '.-- Prop. Line ...1'''. t IiEPAIR/ADDITION(Prev. Sanitation Permit# --------.--------•............. . .......... Date ................. . T Septic Tank [Specify Requirementsl ________________ Disposal Field (Specify Requirements) -------------------------------------------------------------------••-•..........................---------- ................... -------•-----------• 3 raw 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 became subject to Workman's Compe tion laws of California." Signed ----- -- -- Owner By ..r�-T= Title _......_.f.�- .'.-- (If other tha nerJ ........ ........ ................... —_ FOR DEPARTNMNT USE ONLY APPLICATION ACCEPTED BY _. BUILDING PERMIT ISSUED _..-. DATE ��.:.i2� ADDITIONAL COMMENTS ........................... ...._...____.............. . -------------••-•------ •---•---..._.__..._.....DATE .. .................. �-- - -.. ------------------- -------•------- -- -• -• ._ ...... Final Ins ection b - - •---..._ ._ .....------•-•--._... -._....---- - - EH 13 2h � Rev. SAN JOAQUIN LOCAL HEALTH STRICT -- 8/7h 3M