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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT j l- 6 J� :• Permit Na. ;6-y_-/O 3 -- - _ {Complete in Triplicate) This permit Expires 1 Year From Date Issued Date Issued _-��'� � ! Application is hereby made to the San Joaquin Local Health District for a per 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` -- v__ -XV ----------------CENSUS TRACT --------------4--_------- Owner's Name . ____ 1 _ l - - -- ------- - _ - -�- -- -- -•-------- ---------------------------- --------I-------------------Phone - - -- - Addressz:00- City --------------------- Contractor's Name ---- r.!----------------------------------------------------------=--------License # ------- ---------------- Phone ------------------------------ Installation -- ..__..----•-Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other ---------- ---- - ----------------- Number of living units:------ ____ Number of bedrooms .-- ____--Gar age Grinder ------------ Lot Size .___-�� 'z' �_____________ Water Supply: Public System and name ---- =- - --------------------------------------------------------------Private L� Character of soil to a depth of 3 feet: Sand'❑ Sift❑ Clay ❑ Peat❑ Sandy Loam V/ Clay Loam:❑ ] Hardpan ❑ Adobe '❑ Fill Material ------------ If yes,type---------------------------- (Plot ----------- ------(Plot plan, showing size of lot, location of system in relation;•to;wells,••buildi,ngs, 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:M ------------------ Liquid Depth ___ __.-_-_C___----------- (} 1 Capacity _.. -- Type -------------------- Material__ t14 No. ffC��ompcsrtments --------`Y__-___-_- i Distance to nearest: Well _________ _ _______________Foundation _.-_w- I_-____ Prop. Line ////// �'l// LEACHING LINE No. of Lines ------..3_______________ Length of each line___-_-- _ ____ Total Length -:26- --•-_ I 1A 'D' Box ------------ Type Filter Material ___= ---------- Filter Material -------------------- ....... Distance #o nearest: Well -___7 ;__ Foundation ______J4__ _ Property Line SEEPAGE PIT [ ] Depth -------------------- Diameter ----------'-----' Number -- ------ Rock Filled Yes.[] Water Table Depth _______--___ --------------- Rock Size __-- Distance to nearest: Well --_ -_ - ------ ---_W-Foundation ____Prop. Line _ REPAIRfADDITION(Prev. Sanitation Permit# -------------------------------------------- Dd# --------_---------_--_---- ) __ t Septic Tank {Specify Requirements] - Disposal Field (Specify Requirements) ___________ ------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------=------------------------ ------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------- i (Draw existing and required addition on reverse side) k I hereby certify that 1 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,.I shall not employ any person in such manner as to become subjecttoWorkman's Compensation laws of California." ` Signed')( 1 ---------------- Owner i n - I ' --------------- Title ------------------------------------------- ------ -------------------- t (If other than owner) i ' FOR DEPARTMENT USE ONLY I ��? APPLICATION ACCEPTED BY ----------------- ,rr--------------------------=------------------------------ ----------------- DATE -----/ ------------- BUILDING PERMIT ISSUED ----------------------------- ------------------------------------------------------------------DATE ----------------- ------------------------- ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------- -------------'---------- ------------ ---------- = M I -------------------- -------------------------------------------- ----------------------------------------- Final Inspection by: Date " SAN JOAQUIN LOCAL HEALTH DISTRICT a -R E. H. 9 1-'08 Rev. 5M, '