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„ . FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------------------------- --------------------- Date - o`er'/ (Complete in Triplicate) Permit No; ------------------ -- Date Issued :_____a___ U --------------------------------------------------- This Permit Expires 1 Year From 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/LO ATION --1. _ - C JOB I- - .----------CENSUS TRACT ------f` -��_�__----- 4 Owner's Name -/Y? Pia-LC1 �C''671 ----------------------> -- - -----------------Phone ------------------------------------ �y J Address _. � `� C Gs� � d I City � �d�17 ----p----------------------- -------- �y Contractor's Name -.-- -- --.----- _ /_� -1�1---------------------'-'F---_--License # -T-0 �11____- Phone - Installation will serve: Residence [J.A;5a—rtment House❑ Commerciah:❑Trailer Court ;❑ Motel ❑ Other -------------------------------------------- Number -- -------- ----- --;--Number of living units:.__/.----- Number of bedrooms __ ----.Garbage Grinder' ------------ Lot Size __r �e------ Water Supply: Public System and name ----------- ---------- ---------------------------------------=-----------------------------------------------Private (� Character of soil to a depth of 3 feet: Sand TR Silt fl Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam;❑ Hardpan ❑ Adobe ❑ Fill Material -___ ------- If yes,type ---------------------------- (Plot _________._-----________--(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,) `n PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size_____________________ ----------- Liquid Depth ______________---.__._._-- W Capacity -------------------- Type ------------------- Material---------------------- No. Compartments ----------- . ... .... Distance to nearest: Well __________________________________Foundation ._-_______________.__ Prop. Line --------------- LEACHING ;____________ LEACHING LINE [ ] No. of Lines _.____.__.______.-___ Length of each line____________________________ Total Length _____.-____-___________-_-__ D' Box -----------1 Type Filte Material --------------------Depth Filter Material; ____.__________________________________ - . Distance to nearest: Well _______________________ Foundation ------------------------ Pro peity"ti ”= : ................ SEEPAGE PIT [ ] Depth ______.______'____ Dia eter ________________ Number :_._.__--------------------- Rock Filled Y'❑ No i❑ Water Table Depth ------- ---------------------------------------Rock Size --------------------------- Distance to nearest: Well _________________________ _____________Foundation --------------------- Prop. Line .._............ REPAIR/ADDITION(Prev. Sanitation Permit# ____ _.._-____------------------------ Date _____________._____-_____________) SepticTank (Specify Requirements) -------------- --- -------------------------------------------------------------------------:----------------.- ----'---------------------- Disposai Field (Specify Requirements) 1�✓_s_ _� ____f;k0_0_---_ -- ------ -_---- <-----.c`3/ _-__ ----------- 6 " --------- --------------------- ---------------------- -------- ----------------------------------------------------- --------- ---- ------------------------- --------------------------------- --- - -- (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, 1 shalt not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed --- ------ -- ------- -- ----------------------# -- --------------------------- Owner BY4 ----------------------- Title ---------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY,---_T_ _t_R:-Q-------------------------------------- ---------------------------------------- DATE ------ �7 ------------- BUILDING PERMIT ISSUED ------- ---- --------------------------------------------- -------------------------------- --- ----------DATE ----- -- ----------------------------------- ADDITIONAL COMMENTS --- -- ---------------------- ` ___ .e ___-__ ---- - _---------------------------------------- � -_ -•`••__- — �•______ �—_ .__. Date1 ______________________________________ _ ______ __ __________________ _ -__- ` _ - .- \____._--______________._____.____________.___-. _ --•-------—--—------—--- ------ -- —-- —- -- -- - -—--— ------ - -- --- - ---- ------------------------- ------------------------ Final Inspe SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M