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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ................ 7�-/av ` (Complete in Triplicate) Permit No_.. ................................................. This Permit Expires I 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 described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION p � ' F. rel f ..........CENSUS TRACT Owner's Name ...-- Ie 1�1 2 �a .. _.af.�� .. �?.... .G...................... .............Phone ...........,........................ Address . ..- 6_.7..�._.._.. 5/�_.) �y 9 cI. .....City ..... ....................... Contractor's Name ----0--- ------- .........................................license # ... Phone Installation will serve: Residence W Apartment:House 0 Commercial OTrailer Court 0 Motel ❑Other--• ---- ............................. Number of living units_____________ Number of bedrooms 3 Garbage Grinder ....___..... Lot Size ..� ?�.x..l O Water Supply: Public System and name ................Private (�f Character of soil to a depth of 3 feet: Sand W Silt[] Clay ❑ Peat[] Sandy Loam o. Clay Loam o Hardpan ❑ Adobe 0 Fill Material If yes,type (Plot pian, showing size of lot, Iacation 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 TREATMENT IC SEPTIC TANK ) Size------ a......G_!A......... Liquid Depth ....... .............. Capacity );_2---"��Type _ _c 15_T Material a No. Compartments Distance to nearest: Well ....................................Foundation ...................... Prop. Line .........................I LEACHING LINE No. of Lines ................ ....... Length of each line............................ Total Length ---•........................ 6- 'D' Box ............ Type Filter Material ....................Depth Filter Material ............................................ Distance to nea!st: Well -------------------/... Foundation .._...................... Property Line ..................._.__. SEEPAGE PIT. [ j Depth ... ......... Diameter !Z----.X Naalber ....-• ................ Filled Yes No C" Water Table Depth ........................ .Rock Size f�y-Z %yn-0� . f Distance to nearest:.Well ..... 'T.............. Foundation ....h......__ Prop. Line ,14 _......_. REPAIR/ADDITION(Prey. Sanitation Permit# ............................................. Date ------ ---_.-.-................ } Septic Tank (Specify Re uirements ------------ -------------------------------------------------......-................................................... Disposal Field (Specify Requirements) .......--.._ . . .................------•--•....................................................... ... ----------- _r.'.. - - i- (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. Home owner or Ncen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not,employ any person In such manner as to become subject to Workman's Compensation laws of California." Signed -------------•...... -•-------•---- Owner BY (irr� ------ Title --------- ....... (if other than owner) _ fOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .... -- ---- -- --- ------- ---- -------------------- ..............__.... DATE �� Jz:�:7 ............... BUILDING PERMIT ISSUED -- -----'?....:_..__:`__- ------------------ ------••--•..........................................._DATE - ....................... ..=_. ADDITIONAL COMMENTS ------------1----------------------------- •------.--- . . ---------- ----------------------------------------------------- ------ --•------------------------- ------------------------------------••--- ----------------------•-------------------------------- -----------------------•-•• -----------------•--------- --------------------------------f.. ...... _..------._..... ----------..__........................-_......._....._..------- -- Final Inspection by: .. Date -- .-.. _�./.., �?.... ' Eli J 3 21t 1-bfl Rev. i SAN J AQUIN LOCAL HEALTH DISTRICT 8/7h 3M