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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT , Permit N.....�5 ............:r._. {Completo In Triplicate( ; J x � � 7s ,.................. f Date issued �Id This Permit Expires t Year From Date Issue .................. ;.. . y. Application is hey . hereby made4b the-San Joaquin Local Health District for a perm€t to construct and install the wank herein , described. This application is made in compliance with County Ordinance No. 519 and existing Rules and Regulc+tions: JOB ADDRESS/LO ION .:�.. l o -T ,' ...............................CENSUS TRACT .. . �I } .....Phone .. .._. Owner's Name ........:.....:.......... �O .�� cit Address e ----------- one .. . .. rte_ .. - License # . Contractor's Name __ Installation will serve: ; Residence�partrnent House Commercial❑Trailer Court0 9 Motel ❑Other............ ................................ Number of living units:._.. s.� �.. Number of bedrooms _Garbage Grinder ......._.... Lot Size ....• -•---..�'4- .__._...------------..... ......: .._............................_..._......Private Water Supply: Public.5ysterri and name ---------------- Sand Loom ❑ Clay Loam a� Peat Character of so€I'to a depth Of 3 feet: Sand❑ Silt❑ Clay ❑ ❑ Y Hardpon[3 Adobe ❑ Fill Material ............If yes,y pe............... .......... ws (Piot pian, showing size J-iot;'1acatwi—of system in relation to wells, buildings, etc. must be placed an reverse side.( NEW INSTALLATION: (Nal sept€c tank or seepage pit permitted if public sewer is available within 200 feet,l hh PACKAGE TREATMENT [ 7�I SEPTGTANK } , Size..... .----...----••---... - liquid Depth . .. ...� .. ---__ Material------- _-•--- No. Compartments = -- , Capacity ----=-------- --..... Type"-`•---•--•- ......._. Distance to' nearest Well _. -:....Foundation __......----•----..... Prop. Line ... d ten th of each lisle.-----_-__ -_---------- Total Length LEACHING LINE { No. of Lines 9 g ............................ 'D' Box .....•=•-•-- Type Filter Material ....................Depth filter Materia .............. 1,7,7, F I .-. Pro a Line Distance to nearest: Well _.._:•;- --------- Foundation ..-...-----••-•- p �Y SEEPAGE PIT { ] De #h .-----------•--- - Diameter ............:... Number -..---......--.---:-..-. Rack Filled Yes ❑ No ] Water Table Depth -.--------••-•.--•-••..... --•... ...........Rock Size... m. Distance to nearest: Well ..Founda#ioh ----------- ........ Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ... - ;i� .............! s ate ... ......... �....__.. .................o' Septic Tank (Specify Requirements) . •---....`..................................... d[rc3• Dis osal Field lSpetify �Requirementsl •�• ........... .. - r -•• ------------------------ --------••- ----•--....-..........-.•------•--- . ------ ----- ..................... _._ . .. ....... ------ (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work wiii�ttie 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 4 "I certify that in the performance of the work foe which this permit is issued, i shall not employ any person in such manner i as to become subject to Workman's Compensation laws of California." i' Signed ---•-- .-. •- ----- --------------------I.................-. •_.. Owner -~A` �� ` E •----` Yitle ��U7��G• = gY - -----• -------•--•------------•----•----- (if other than o ner) FOR DEPARTMENT USE ONLY . 00, - APPLICATION ACCEPSUE jjiY �i, -------------•-- _.....--..•----- DATE .-. BUILDING PERMIT IS DATE -------•----._.... ! ADDITIONAL COMMENTS!---------- ............----..................•-•----•---•-•-•-••-.-........... ................--.-..-..-..----- :..-..._...-..-...--.._...-- ------------ -- --------- --------- --- ----------•--•-------•--••-•••-----•--- -----•----••-------•----------- i�. ---------•------•--•--•-•--------------------------- -- - - i�..-. -------•--••----------------------------------------- -----_--- .....-- .-... � �• �.� -- Final Inspection by: -•---.....: .....------- -- -•- ...----------••---•----•--•----••........................ ----- Date -. 1x1-1'13 24 1-68 hevh 514 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M