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FOR OFFICE USE. �_ gyp. o-a . � APPLICATION FOR SANITATION PERMIT T# r- -------- Permit No: (Complete in Trilsiicate) 4. ------------------------------------ _______________-!i___ This Permit Expires 1 Year From Date Issued Date Issued- _`� __�� t Application is hereby mad- to the San Joaquin Local Health District for a permit to construct and install the work herein . deseribed. This application:is made in compliance with County Or inance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION :__ -�---C__ ------- Q.C ! °/J--'------ ----------------------------------------------CENSUS TRACT --- ---------•----•-•- Owner's Name ----- �� 12 5 --------------------------- ----- -------Phone ------------------•----------------- Address --� ----------------------------------------- city f�G°f __ t �) - ------------------• -- a 12 Contractor's Name -_ - - ---•.- /� .�--'{ ------------------------------.License #r _ �_ Phone _L�7_ Installation will serve: Residence ❑Apartment House❑ Commercial:❑Trailer Court ,[] Motel ❑ Other ----- -- Number of living units_____________ Number of bedroom -------Garbage Grinder ------------ Lot Size 70__>e�_--_____________ Water Supply: Public System and name ____________________ ----------------------------------.---------Privat9w, Character of soil to a depth of 3 feet: Sand Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ro 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: (Nol septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] : SEPTIC TANK f ] Size__{�j.__ ?ea--------- quid De th `s) Li p — , Capacity D___,__ Ty _C r,*-�Material __ ____ No. Compartments � i Distance to 'nearest. Well ___41 ?------------------------Foundation 6___: _______ Prop. Line .__________.______ LEACHING LINE [ ) No.'! of Lines -�___________________ Length of each line---1O4-f------------ Total' Length _. !�_----_____-- 'D' Box __fesType Filter.Mafierial th Filter Material 1� p t . ,/ ----- . Distance to nearest: Well ------ Foundation __f 1.ff---- Property-`uner-__ __.___-____. SEEPAGE PIT [ ] Depth Diameter _ _------- Number ____._� ----------------- Rock! Filled Yes ❑ No J0 Water Table Depth ------------------------------------------------Rock Size ----------- 1l ' Distance to nearest: Well _____________________________________--Foundation _____:_____________ Prop. Line ________..____--_--- REPAIR/ADDITION(Prev. Sanitation _ Permit# ________ _------------------_____-________.__ D ate -----------------_____-____•-___ SePtic Tank (Specify Requirements) ----- _ . _________ --------------- -------------------------------- ---------------------------- ---------•----------------- -•-•---- '-- 'Disposal Field (Specify Requirements) _______- -------------- ---------------------------------- t ---------- ---------------------------------------------------------------------------- ---------------------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 licen- sed agents signature certifies!the following: "I certify that in the performance of the work for which this permit is issued, 1 shall note-employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ---�p ! 1 Owner , 80Y By -------- - ------------------------------------- -Title --------- -------------- (If = other than ow ) ��. FOR DEPARTMENT USE ONLY ;r � APPLICATION ACCEPTED BY,-_ -- ------ -- --di-�0--;---1 -A(----------- •► dd.�7�--------- J ---=------------------ -------- DATE -----�-� d----•--K- - BUILDINGPERMIT ISSUED ---ll--------------------- ---- --------------------------- --------- --- ------------------------------DATE ----- ------------------------------------- ADDITIONAL COMMENTS ---H__.______________ _______ ___ __ - ------------------- -- ---- ----------------------------------------------------------------------------- ---------------------------------- ----- ------------------------------------------------------------------- ----------•-------------------------- - --- ------------------ --- --- ----- ---------------- ----- ------ ---- Final Inspection by. ','- ------------------- _ -Date = SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M t