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FOR OFFICE USE: 73.. /1.30 APPLICATION FOR SANITATION PERMIT ---- Permit No: (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: f J,J - /'/l— 2��0--zs— JOB ADDRESS/LOCATION ._._--_ ` _ `�` / ------CENSUS TRACT ------------ - --- ------------------------------------- Owner's Name _� _- / ------4"' _ -------/J"-- A?� ------------------------------------------ ---------- --------Phone: 4-�` -T1 Z Address sc? a- ---- __ City fD --•- ----------- /, Contractor's Name -- ,--/=-�.---------X�-- -/,f_-" --------------------------------License #2_va-��_�Phone �� Installation will serve: Residence ❑ Apartment House❑ Commercial :❑Trailer Court !❑ Motel ❑ Other cd '----------------------- Number of living units------------- Number of bedrooms ____________Garbage Grinder ------------ Lot Size _ _ _____.___-_lel5p-- -___________ Water Supply: Public System and name ------------------------------- ---•---------------------------------------------------------------------------Private �. Character of soil to a depth of 3 feet: Sand'❑ Silt(] Clay ❑ Peat❑ Sandy Loom)< Clay Loam ❑ Hardpan ❑ Adobe'❑ 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.) U` NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT { ] SEPTIC TANK [ ] Size------- _ a_x ------ Liquid Depth _d_-________-_________ Capacity -0 G-.__ Type _ a-0--- Material__ '"_ No. Compartments ------A=___-___ Distance to nearest: Well --------(tz CJ------------------Foundation ---------- Prop. Line ._.�______:__._.... t LEACHING LINE [ ] No, of Lines _-__/--------------- Length of each line-------- --------- Total Length ___ --------------- �i .. 'D' Box ------------ Type Filter Material 4n-----Depth Filter Material ..../9________________________________ Distance to nearest: Well ________________________ Foundation ------------------------ Property Line- ___________________..._. SEEPAGE PIT [ ] Depth ___________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑; a Water Tablet Depth ----------------------=--------Rock Size --------------------------------- Distance ---------------------------- -Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# --------__---------------------------------- Date ---------------------------------- V � Septic Tank (Specify Requirements) --------------------------------------------------------------------------------------------------------------•----------------------------- i Disposal Field (Specify Requirements) ----------- ---- ---------------------------------------------------------------------------------- --------------------------------------------------------------- ------------------------------------------------- --------------------------- - ------------------------------------------------------------------------------------------------------- (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, I shalt not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ---- '-- --- ----- -- --- 4 Owner BY - -- --- -_61---------------------- ----------------------------------- Title -- ------------------------------- - (If other than owner) ' FO PARTMENT USE ONLY APPLICATION ACCEPTED B ---------------- *.. DATE -- �� 6 ------------------ BUILDING PERMIT ISSUED --- --------- DATE ------------ ----- ------ ADDITIONALCOMMENTS --------------------------------------------------------------•--------------------------------------------- ------ ------------------------------------------ ----------------------------------------------------------------------------------- -------------------------------------------------- -------- ------------ - - ------ -- --------------- -------------------------------------------- --------- -- --- ----- - - - - --------------- --- ------------------------------------------------- ----- �/ Final Inspection by: --------------------------------- ---------------------------- Date SAN JO QUIN' LOCAL HEALTH DISTRICT r E. H. 9 1-'6$ Rev. 5M