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—. F FOR OFFICE USE' APPLICATION FOR-SANITATION PERMIT Permit No. (Complete in Triplicate) ----------------------------- -------------------------- �,2,.9 '/ - Date Issued ___-__-._--________ - This Permit Expires Y Year From Date Issued ---------------------------------------------- Application is hereby made to the San Joaquin Local Health Distiict fora 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 _ __ JOB ADDRESS/LOCATION . -_ - -_ --- ------- -- ------ ------- ------ ---CENSUS TRACT ------ � Owner's Name ----R1-]Nt K------ 0&1-L ----- Q_� - Q � Phone Address _Al1Cpo------ ------4 ---- City �wN : Contractor's Name ---- ._._ -------License # ----- -------- ---- Phone----------------------------------------------------------- - --- ---- -------------------------------==----------------- Installation will serve: Residence ❑ Apartment House[] Commercial ❑Trailer Court Motel ❑Other --------------------------------- ------ Number of living units:_- --------- Number of bedrooms ------------Garbage Gr"index --- J.Lot Size _-__-_-__________________________---____- Water Supply: Public System and name __ ' ---------------------•Private ❑ Character of soil to a.depth of 3 feet: Sand'[] SYIt.❑ .i Clay ❑ Pegt Sandy Loam Cla Loam .t L.. :Hardpan [] Adobe ❑ Fill Material XV9 '_ if yes,type ___________________________ (Plotplan, 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 TREATMENT [ ] SEPTIC TANK'[ ] Size---------------------------------------- --- Liquid Depth ---------------------.----- Capacity -------------------- T Pe' ----------------- Material----------- - o. Compartments -----------__------ Distance to nearest: II ------ ---------------- -----------Foundation _- --- -------------- Prop. Line -------------_------ LEACHING LINE [ ] No. of Lines ---------------- ------- Length of each line------- `--------------- - Total Length ------ ------------ 'D' Box ---------0 Type F Iter Material --------------------Depth�Filter M erial -------------------------------------------- Distance to nearest:,.W It ________________________ Foundation ------------------- ---- Property Line ------------------------ SEEPAGE PIT [ ] Depth ____________________ D • meter ---------------- Number ----------------------- ___ Rock Filled Yes E] No Water Table Depth 1 _ ----------------------------------------Rock Size --------- -------------------- Distance to nearest: W II _!14�------------------------------------Foundation ---- ------------ Prop. Line ----------•------- •--- REPAIR/ADDITION(Prev. Sanitation Permit# - - -------------------------------------- Date --------•--------- --------------I Septic Tank (Specify Requirements) -------------------------------- ' = ---•-------------------- ------------------------•---- ------ ------ ---- Disposal Field (Specify Requirements) _____r4Dj>------- 45.7-------- -F/_CrER-----13f D---------------------------- `f "-------,� -----'--->�5--------- b �r7 _a�1 N -------- ---- ---l_ . '�`I_n� __ __ �t� r a --------------------------- --------------------- ----- ---------------------------------------------------------------------- ------------------------------------- (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 in the performance hew rk fo which this permit is issued,'1 shall not employ any person in such manner � as to b me subject to Workma am nsati. n laws of California." Signed '----- --- - --- -------- -------------------- Owner 9- ----------------------- ------------------------------------------ By ----- ---------------------------------------------------------------- Title _ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------f--' _!�O----------------------------------------------------------------------. DATE �7 4--------- BUILDING PERMIT ISSUED - --------------------- ----------------DATE ------------------------------------------- --------------------------------- - ADDITIONAL COMMENTS __ - ------ ----------------------------------------- ------------- --------------------------- ---- ---- - ---------------- --- ---------- - -- --- = ------------ -------------------------- -------------- --------------------- ------ 6;�rZ f� ------- ---- - ----- --------- ----- ate Final Inspec ' - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev- 5M