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FOR OFFICE USE: Ile - ' APPLICATION FOR SANITATION PERMIT } f� -- -----•----- --------------- ---------------------------------------------- --------- - -- (Complete in Triplicate) Permit No. ---------------- This Permit Expires 1 Year From bate 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 application i; m � cWpliaanc with County Ordinance No. 549 and sti g Rules and Regulations: '513VV J. st R �f JOB ADDRESS/LOCATION _L{� -_ Se-.--1 ,/ G'Qf ti-L -------Pav, .-T ------CENSUS TRACT �0 = Owner's Name v-t<--- ---PQ v 4-Ty- -------------------------------------------- •--------- ------ --Phone.-2t�75i`91:7- Address ----------- �� ` e Cit Y f2_J Q IV --- - - Contractor's Name 11 /5-01✓r ' bt -------------------- --------License # - J/ - "'a � Ph Phone J Installation will serve: Residence ❑Apartment House°❑ Commercial:❑Trailer Court ❑ �. Motel ❑Other -------------------------------------------- Number of living units:----l___-- Number of bedrooms ---�------Gar bage Grinder A/V----- Lot Size .---_AG"a Water Supply: Public System and name -.-__--- -__-_ ------------------------------ ----------------------------- Private _ Character.of soil to a depth of 3 feet: Sando Silt❑ Clay :[] . Peat Sandy Loam Cla Loam, Hardpan E] 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.) G' I NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------- �+ - --------•- ---------- Liquid Depth ----- ------ Capacity ------------------- Type -------------------- Material------- -------------- No. Compartments ----------- ----------- Distance to nearest: Well ------------------------------------Foundation .-.-------------------.Prop. Line ---------- ------ LEACHING LINE [ No. of Lines ------------------------ Length -of each line--------------------------- Total Length ,_-_-_--.-_.._ 'Q' Box -------- -.- Type Filter Material --_----------------Depth Filter Material ---___---__----._-----• - Distance to nearest: Well ------------------------ Foundation -------------- Property Line SEEPAGE PET C l Depth -------------------- ------- --- Diameter -:------ Number -------------------- -------- Rock Filled Yes E:1 No fl] p Water Table Depth --------------- --------------- ----------------.Rock Size Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------------------- REPAIR/ADDITION -----•---------------REPAIR/ADDITION(Prev. Sanitation Permit# --- Date Septic Tank (Specify Requirements) cFY - -------------------- - ---- -- ---------------- - - n -Disposal Field (Specify Requireme _ A : ,�� r t/i -------- D ---- �' �',-'_r. err % ------------------------------------- .. - ... (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 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed __. -- ------- - 4-- 9 v� - ----- Owner BY ---------------- ath --Z-- Title ---- - ------------------- ---------- -(If (If er ner FOR .DEPARTMENT USE ONLY ' APPLICATION .ACCEPTED BY _. ' f '�1`-0----------------------------------------------------------------------------- RATE 4l� -� BUILDING PERMIT ISSUED _---.-__.- ADDITIONAL COMMENTS - -------DATE ----------•--•---------- ------------------------------- ---------------------------------------------------- - ------------------ -- -------- - Finallnsp I , - - --------------------------------Date [ � j SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M. i .