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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .. (Complete in Triplicate) Permit No_ 4 ----------- --_-------- 4 - + / ________________ This Permit Expires T Year From bate Issued Date Issued ____ _________77 .. 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 ma)e in compliance with County Ordinance No. 549 and existing Rule's and Regulations. t� JOB ADDRESS/COCA _(1_----R -- -1 - G�f Q n -----------CEN90SYTRACT ---- - -_1.- ----'-- Owner's Name `w f iLG -7�c9,ni_ ! ----------- �-_--`g-----------------------• --- Phone r`' ~ CNZi 6 7 �6 Address ----------- - ---- -----. y - Contractor's Name ---A-_L.____._ �� "'- ------------------------ ------License 4V,r 9--- Phone Installation will serve: Residence 7Apartment House'❑ Commercial:❑Trailer Court i❑ T Motel ❑Other -------------------------------------------- ,a / Number of living units:------ ---- Number of bedrooms 3 ---.Garbage Grinder ' __ Lot Size �, �_% Water Supply: Public System and name ------------------------ ---------Private ----------------------- Character of soil to a depth of 3 feet: Sand'❑�,,,Sllt❑ Clay 0 Peat❑ Sandy Loam ❑ Clay Loam Hardpan% Adobe ❑Fiil Material ------------ If yes, type -------------___________ (Plot Ian showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) p g y NEW INSTALLATION: (No septic tank or seepa pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT f ] SEPTIC TANK ,, Size--- ______________ Liquid Depth __lam--------- Capacity __-_ -_Capacity _4__P-0-------- Type ------ No. Compartments -----a-- J f kP �. stance to nearest: Well --- `: ------------ -Foundation --------------tProp. Line -- ---- •-.•--__1 00 LEACHING LINE No. of Lines -----L!k--------"-.__ Length of- ach fine____ __7S__ Total Length 15.0___ _ --------------- /0--_ --- - % D' Box ----/ Type Filter Material /:d_: -Depth Filter Material Distance to nearest: Well ------------ Foundation ----- --------- Property. Line _______________ I SEEPAGE PIT Depth --------- Diameter_ Number .___ Roc Filled Yes No 0 � ----- �, Water .Table Depth ___..Rock Size/ne- Z_; ----- ;y; �. r- -- ---Q .. -Distance to nearest: Well _______�____ ____________________Foundati -Prop. Line ____.__ --__ tp ^� REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------------------- --- pate ---------------___:--•--_--•___-} -,�' ., . i y Septic Tank (Specify Requirements( = ------------------------- - - --- Disposal Field (Specify Requirements} ______-_--_ ` - -------------------------- --------------------------------------------------- w- ---- - ------- -------- -------- ----------- - -------------------- - ------------------------------ (Draw existing and required addition on reverse side) I hereby certify that I have ,prepared this application and that 'tFie work will be done in accords to 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 orkman' ompensation laws of California:`'.. I Signed ------- �- -- -=----------- Owner # By ---------------------------- -------------------------------------------------------------- Title/------- --- -------------------- ---------- (if other than owner) ! FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY I -t---- ---0-'------------------- ---- ------------ = DATE �_-_�` ------------------- - ---- BUILDING PERMIT ISSUED ---------------- ----_-- ---------- -----------------DATE --------------------------------- -- ADDITIONAL COMMENTS --------------------------------------------- - - ------ ------------------- ------------------------------------------ - ------------------------- ------ ---------------- -------------------------------------------------------------------------------------------------------------- --- -------- - ----- --:--- ----- ---- - - ------- -------------- ---------------------------- --------------------- ------- -- ------- -- ---- ---- a_. --------- Finallnspec ;. -- --- --- j 7 - -.Date SAN JOAQUIN LOCAL HEALTH DISTRICT E H 9 1-'6$ Rev. 5M