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.FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .............................................. • (Complete in Triplicate) Permit No. -.. !q -----••---•---------------• This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a -permit to construct and install the work herein . described4s applicatio m e n compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCAT N .r ,.[?t...:------ - �,_- x/� "A-`" '�W/bNSUS TRACT .......................... ...............:._... Owner's Name-: Phone --._..._..,�----..._..::._.......... Address- .....,-- I ........... City .... 2fl9 83`-03 � 3 ,vols ti , ...�- -� � .,.... • < �_./f .rn .r�'.t�., ----.License # -Kl. ..:`.. _�1 Contractor's Name . Phone.. Installation will serve: Residence ffApartment House❑ Commercial ❑Trailer Court 0 " f.. � � I ;Motel ❑Other --------:........................ ... ... . Number of living units:...-I---- Number of edrooms ---1......Garbage Grinder i. Lot Size Water Supply: Public System and name ;------•-----•-------- - Private ❑ Character of soil to a depth of 3 feet: 1! Sand E] t.❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam [] Hardpan 0 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,) PACKAGE TREATMENTSize. ' [ l SEPTIC TANK ] I ti--=-=----- Liquid Depth ...... / Capacity _�� ype Material- No. Compartments ...../` .... .. . --, Distance to nearest Well __• ._...___.__Foundation /<3_.......... Prop. Line .....5.......... LEACHING LINE [ ) No. of Lines ......... . ........... Length of each linegD.-3U_:-4:a.4�Total Length ..... ...... D' Box .__:,�__.: Type Filter Material � �2*1--.Depth Filter. Material ... .. ----•---------------------•- Distance to nearest: WWII --.-__--- _.---- Foundation _.....____:. Property Line SEEPAGE PIT [ ) Depth .................... Diameter ..._....._...... Number ------------------.......... Rock Filled Yes ❑ No i0 •. Water Table Depth •------- .._.. . Rock Size - . -- . Distance to nearest: Well .............. t...........Foundation ................. Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -•--•--- .................. '7'-.. _...___.. Date .........__... [ - I ........•........... Septic Tank (Specify Requirements) ..................._. : i -------•-•-••••-- Disposal Field (Specify' Requirements) �• ... ............•-----•-•--•----•-------- ............................................................. ............... --•--------•-- =` •• - (Draw existing and required addition on reverse side) ' i hereby certify that 1 have prepared this applle ,gn an"h t the work will be done in accordance- with San Joaquin County Ordinances, State Laws, and Rules and Ragulotlons of the San Joaquin Local;Health District. Home owner or Rin- 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 .. �✓,r✓ _ ; 4_4:.....--•••-.._ Owner By --cam- --+E ...... -- j - ------- -------------•---------.......--•... Title (If other than o ner) FOR DEPARTMENT USE ONLY ; APPLICATION ACCEPTED BY lfJ.tc�C i ............. -----------------------------------------------_-- ADDITIONAL COMMENTS ....................•••_•- ............................................ .------•-----•----------•--•................. •--•-----------•-•--..... . .•-•.. ...... ti ...-•-•• •-••---••--......--•• •• -•-•---•• . _..... _...; .....:..-----••-••-•--•-- ...-•••-•.....•••-- ................................._ . ........ I Inspection by: .. "'" _ •......�..A*V...... ............................._ •---..Date . .f�.. SAN JOAQUIN LOCAL HEALTH DISTRICT=t