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FOR OFFICE USE: sVAPPLICATION FOR SANITATION PERMIT Permit No: �� ---------------- --------------------- •. (Complete in Triplicate) - ---- ---------------------ren__ = - - -= - h - - --- Date Issued 'JIF--___- This Permit Expires 1 Year From Date Issued Application is hereby-malde to the•San Joaquin Local.Health District for a permit to construct and install the work I erein described. This application is made in compliance with County Ordinance No. '549 and existing Rules and Regulations: jr /IIQ/Y�T -- -----.__CENSUS TRACT __ '`S} ----- JOB ADDl2E55/LOCATIEN -!___-�1' _ �-moi°---�/F---- Owner's Name ----------------------------- :-------------------Phone Address -- ..�_/4 L _..,. ----------------------------------------------. City � eiW_7 h�------------------------------------------ Contractor's Name ----7 -- . ----------------------------- I ----------- - License # _ � Phone Installation will serve: Residence 2 -Kpartment House❑ Commercial ❑Trailer Court ',❑ i Motel ❑Other -------------------------------------------- j y l Number of living units:---- ------ Number of bedrooms __._.Garbage Grinder Lot Size __.------------- r- � �� l� 1✓,�� ----- --Private Water Supply: Public System and name -----__J__X________----�-_�-4__-_ -- -- ❑ Character of soil to a depth of 3 feet: Sand'RD---Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam,E] _ - - -- - Hardpan ❑ ""Adobe ❑`-.Fill Material=:="____:_:.If yes,type---------"-:---_------ i (PlotIplan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) INSTALLATION: JNo septic tank or seepa a pit permitted if public sewer is vada le within 200 feet,) tI j PACKAGE TREATMENT € ] SEPTIC TANK Size__ i - ---------- Liquid Depth ------- -------- Capacity/,&p----- TypJW =--Tom!°--- Materia No. Compartments -2--------------- Distance -to ------ --Distance to nearest: Well _41" �-----------------Foundation ------ Prop. Line:-.X-Z- f----_•_ -------- LEACHING LINE [Ir/No. of Lines -----/---------------- Length of each line__?0-_ ------- ------ Total Length ,___ Q•_________ 'D' Box 4141--- Type Filter Material PVPC _ _______Depth Filter Material � - -- Distance to nearest: Well__ . ,_ Foundation /0------------------ Property Line ---Q---.------ SEEP\GE ----SEEPAGE PIT [ ] Depth -------------------- Diameters ------------- Number ------------------------ --- Rock Filled Yes ❑ 0 0 r' Water Table Depth _�`^""--~"—" _R�ck Size # Distance to nearest �ell -------------------------------------=Foundation --------------- ---- Prop. Line -•--------:---: r,-- REPAIRfADDITION(Prev. Sanitation Permit# ----------------------------------------- iatel--_--------------------_----------1 -_..---------------- ,.i } Septic Tank (Specify Requirements) �' � � _�1 .,�t � Disposal Field (Specify Requirements) ----- -- � i W, 1----- �--- -------------------------- -�-------------------------'------------------- -------- --------------- ------ -. s,a "- �: -- - ------------------------- 4 ------------------------------------------------ ------ ` _------------------------------------t--- + [Draw exiting and required addition on reverse side) I hereby certify that I have prep�red this 'application and that the work will be done in accordance with San Joaquin County Ordinances, State .Laws, and Rules a6cl Regulations f the San Joaquin,Local Health District. Home owner or licen- sed agents signature certifies the following:j. j i a+ } . "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." y Signed ----- / '----------- ---------------------------I---- ----- Owner ,p BY -- ' - ------------- -- ----------- -------------------------- Title - /ft9Pr/!' Xt , a----- [If ofiher than owner)i - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ._-_ -R- ----------- --- ` DATE ---- - --ZS- - - ----'-- --- BUILDING PERMIT ISSUED = -IL -DATE ADDITIONAL COMMENTS ------------ --------------------------- -4---------------------- -- ---------------------------------- ° - -------- ----- ---------------= ---- ---- ------------------------------------- --,f't------:---------- --------- ------------------------- --------------------------- . ------------ - --- - - --------------------------------------- ---------- = - iFinal Inspe `--------------------------------------------------` Date ---- -------�--- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.