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= FOR OFFICE USE: is - r APPLICATION FOR SANITATION PERMIT ..1�. ._.-. ..... . - (Complete in Triplicate) Permit No. ------------------------.----------------------.......... This Permit Expires 'I Year From Date Issued Date Issued /l_/-_7 - 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: n_ JOB ADDRESS/LOCATION ...�. �Ql------t y'�"1Na� ---------------------CENSUS TRACT .......... Owner's Name ---------------------------------------=-----------------:---------------=- -------------------Phone �5 p94-� ----------------------------------•---------------------------=� Address .... ,- '��-'"e ---'- ----------._. City -- -------------------------------------------------•------ Contractor's Name _Lf�W- ------------ -- i --------------License # ------------------------ Phone ------------------_--• Installation will serve: Residence WApartment Hous6,❑ Commercial ❑Trailer Court ',❑ 1_ .�------Garbog Motel F1 Other ----- --------------- -------------- -• - --- R Number of living units:----- . ___ Number of bedrooms l ��'�`S Garbage Grinder - -- ---- Lot Size ------------------------------------------ Water Supply: Public System and name ---------------------------------•---------------------------- ------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ 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.) NEW INSTALLATION: (No septic tank or seepage pit-permitted if public sewer is available within 200 feet,) \ PACKAGE TREATMENT { I SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth ------------_------------- �V v n Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------•--_---------- Distance to nearest: Well ------.Foundation ---------------------- Prop. Line ..__-------------..._. �. LEACHING LINE I ] No, of Lines --cl----------------- Length of each line------95--------------- Total Length _-l ............ 'D' Box _) _. / ----- Type Filter Material for,_K--..Depth Filter Material ....��............................... Distance to nearest: Well qo.f.............. Foundation A9 Property Line M?------------------ r / I SEEPAGES [ ) Depth �.-ly1•________ Diameter 4_Xt0.. Number ......)------------------ Rock Filled YesX No i❑ / y li '- SUW Water Table Depth --1`Q--------------------- ---------------Rock Size 9 �J-sA------------------ � Distance to nearest: Well _IaC ------------------------------Foundation AO-' ---------- Prop. Line --too------------ REPAIR/ADDITION - oo-----....._- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------- ----- ------------------_------------ Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------ � - (Draw existing and required addition on reverse side) 1 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 shall not employ any person in such manner as to beta a subject to Workm nq s Compensation laws of California." 5igned7t --, ---- - ^ ------------------------------------------------------------ Owner l By --- ---------- ----------------------- ---------------------------------------------------- Title ----------------- ------------------------------------------------------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .---- ------------------------------------------------------------------ DATE -----//-A_!L------------------ BUILDING PERMIT ISSUED ---------- ---------------------------- --------------------------------------------------- DATE .----------------------------------------- ADDITIONALCOMMENTS ------------------------ ------------------------------------ ------------------ -------------------------------------- --------•------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------- --------------------------------------------------------------------------------- `------------------------------------------- ------- ---- ---------- - - - ---- ----- ------------------------------------------ - - - - - - - - - - - - q Final Inspection by�. ----- ------ -----------------------------Date ------ f� �� ---- ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M G