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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - ---- ---------------------------- (Complete in Triplicate) Permit No: G_ r1 34 ______________________________ This Permit Expires 1 Year From Date Issued 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 ap lication is made in compliance with County Ordinance' No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION � 7------.-A4_4})(WELL-------4-4.N E� CENSUS TRACT --- --- Owner's Name ------T�_I LLI__P.. ------COW-`�T------ � Phone Address �J. ------- L T - ---------------- City -------4A_T Q Contractor's Name --j'Nf4._0.P- ------C'_f�-n[_``_ r-------- `-----------------License # -------- -------------- Phone --------------------------- - Installation will serve: Residence �parftnler t•House_'[] Commercial:❑Trailer Court ,❑ j Motel 0 Other -------------------------------------------- Number of living units:----!_------ Number of bedrooms -_ 1[��Garbage Grinder /V0_'_ Lot Size - ____ -_- ------------- Water Supply: Public System and name --------- _------------------------ ----------- Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loom lay Loam.:❑ Hardpan ❑ Adobe.'❑ Fill Material O---- 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 seepciae pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT CopacSEPTIC _ TANKSize_-::_ _ 'Liquid De th ___ —: , _a __-__ oCompartmentsPNae Q Distance to nearest: Well ------ .VV`---------------Foundation _A9___'_.------- Prop. Line _____ _______--_-_ LEACHING LINE i[ ] No. of Lines _ __. Length of each line_._____ T" �Toal Length -' ?... ..._.-. Y ---- - .._.:.: v 'D' Box Y- 5- Type Filter Material _ U _.Depth Filter Material ------ _ _r'` E ."F Distance to nearest: Well __-_�_-�--_--- Foundat.ion _._-__ _--_----._- Property Line ---1?_____ _________ j , SEEPAGE PIT [ ] Depth ---------------': _ Diameter -------- sr Numbe 'k'4-- ---t--_.-_________ Rock Filled Yes ❑ No _ t Water Table Depth • L Rock Siie ----`- • --------- ' I Distance to nearest Wel! -�'�' ___________ (___Foundation Prop.' Line .... ................. REPAIR/ADDITION(Prev. Sanitation Permit:C# -=------ ---------------------------- - Date -------------- •. - ; Septic Tank (Specify Requirements) -'�'-_� :- ---------------------------------------------------------------W ----- -�=--i.- •- - .__,._.------------------ ------- Disposal Field {Specify Requirements) ------(�+t; JJDT}-!' ------"-rA,-"-NC,1-1--------- f¢ - ---------------- -1--' -- ----------------- ----------- ---------------------------=----------- - f ------- ----------------------------------------------------- ti t --- --: -- ---- ------------- ---- --i. a i t^ fDraw exi'stingand'r"egvired�a&I`it+on on reverse;side) 1 I hereby certify that I havelprepared this application and that the work will be done in accordancewith 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: l J? t "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 Conipe" ration laws"of-California:" "'" Signed - _�_______s '_A ------------------ Owner i BY = ----------------- Title --------- ---------------------------------- - '---- ---------------- (If F------------- (If other than owner) j. { FOR DEPARTMENT USE ONLY # APPLICATION ACCEPTED BY .-'-T-( DATE ------ .-:2 --------- BUILDING-'PERMIT'ISSUED------------:.---- -- - ------------------ ` ------- ` i ADDITIONAL COMMENTS - ---- ----- ..�.f,! __: .VJ'" i"k f� , 4-: - ----_ _�=-------- - ^ - ---------•_--------_-----------------------------•--------------- - - - - ------------------------------------------- --------------------------------- ------------ ------------ --------------------------------- - r -- ------------ 4---- ---- - - ------------ -- ---------------- ------ Final Ispp � --------------- n - - . SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1268 Rev. 5M