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FOR USE: " APPLICATION FOR SANITATION PERMIT ----------------------------- ----------I--------- --------------------------------- ----- ---- (Completein Triplicate) Permit No. ---"------ --- ----- This Permit Expires 1 Year From Date Issued 7 ----------�- Date Issued - Application is hereby made to the San Joaquin Local Health District for a 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 ADDRESS/LOCATION .___-_ __ . c - � �/Qa �� _ - ¢G -7'4*I_CENSUS TRACT ----N�— ._ _ .------------------------------------------------ •Owner's Name --- � ------ -------- --Phone --�--------•- - Address ----------- ----------------- ------- City ------ --------- -------------------- City --117L/Cr�--- - --------------------------------- --------------------Contractor's Name ---- - --- -- ---�._-- - _4w-0r/�-_- --_- --.._. _ .._..._ _- ❑ p --- --- ----- - ------ ---License # -4'70771 ----- Phone ----------------------- Installation will serve: Residence Apartment House n t'.,.,,�,;__i..r _ f � ( Q /�L ? License No-L�73Phone `" D Contrzctos carnage Grinder ---- -Q Lot Size �e Water Supply: Public System and name ______- --------- •------ . r _ + -----.-Private Character of soil to a depth of 3 feet: Sand❑ Silt El Clay ElPeat E] Sandy Loam ❑ Clay Loam f] Hardpan f] Adobe X 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) " PACKAGE TREATMENT f ] SEPTIC TANK ] // Size---7a _-- n - Liquid Depth _`5�7� f' , _ ,'� Capacity 1�D0�.�f-- Type A7�dR /4/ Material__t5,,vcr ___--- No. Compartments Distance to nearest: Well ------ Foundation 7� e`�----�-_ Foundation _14�'�ls_ Prop. Line LEACHING LINE [ ] No. of Lines __-_._ - - -------- Length of each line_---- 9� - - ------ Tota! length --- --1-�r0--- --'•-•-- D' Box ------�-_._ Type Filter MaterialG--� Depth Filter Material -------�� - // ��/ > - ----- - ------------- X- - - -- Distance to nearest: Well S - _ti X- Foundati n ��7?, /uS._- Property Line SEEPAGE PIT t f 1 Depth -------------------- Diameter ----- Number ----- ------ --------- - _______________ Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size ------------------•---_--- Distance to nearest: Well _______________________ ___-__Foundation __._--___._ --------•-- ----•---. Prop. Line -------•-------- • - - AIR ADDITION(Prey. Sanitation Permit# ___-___ ------------------------------------------- --- Date ----- ----------------- Septic Tank (Specify Requirements) ----___________________________________ Disposal Field (Specify Requirements) ------------------/---�- -- -O � / A. ----------------------------------------------------------------------------------------------- -- ------------- ----------------------- Zired �. � r ------- --- ------ (Draw existing and req addition o everse side) t1) 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 an as to become su Iect to Workma ensation laws of California." P y Y person in such manner Signed _- - Owner BY --- ---moi =- - -- - ------- -- Title ---- - r - - - --------------- ----- -------- er than owner) -------------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . �� rr- Ile ' BUILDING PERMIT ISSUED ` ----- ------ - - DATE �di -- ---------------- DITIONAL COMMENTS DATE -------------------•------------------- ------------------------------- ----------- ina Inspection by: _ - ---------------- ------------------------------------------- --- --- ----- - - ------- Date --- -� - - - -- - - - ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M '" C t