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L: FOR OFFI F LJStr: APPLICATION FOR SANITATION PERMIT 1Complete in Triplicate} r� Permit No. ......?�............ f ........................................................ 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 application is made in compliance-with County, Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCA ON .._ /..��_.. ®�o ................. t ... s: :................. CENSUS TRACT ............. Owner's Name ._. ._.8 ��,%.. �. ----- .....Phone t.... - p y� y� Address ... J-; ... .... F. .S1.- -fir.-----... -------------------- City /lam 1(/ .............. .................. i Contractor's Name ...�� ..�--.=r�� -------- I...............................License # �f c --- Phone '- 1'?--- Installation will serve ~ Residences Apartment House,❑ Commercial ❑Trailer Court �] Motel ❑ Other .. ------ i Number of living units:... Number of bedrooms �......Garbage Grinder.... Lot Sizee.�(/V, _.# ................ Water Supply: Public System and name ---4� �`'�Y 6 1 1�''� �11'�� . .............................Private ❑ Character of sail to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ x Hardpan [] .Adobe)& Fill Material -.-......... If yes,type ........... ................ X (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 p blit sewer is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK ze. ......... Liquid Depth f .................. r rG' "... i Ca _. p�ocit•_y ..� ©-a..... Type- _.� .._ Materialewfs. .i�_._.. No. Compartments Z Distance to nearest: Well . _.- ..-�--------------Foundation /40,......... Prop. Line ......... LEACHING LINE No. of Lines ... .... Length' of each fine_ V� ... . i � - ----.._.... Total Length �./_.�................. ,A 'D' BoZ0,4nearest. �"—Type Filfes Motorial � Depth alter Material ..........:............................ c Distan Well __. `....._... Foundation Re./.............. Property Dine- �-/................. :-, per; . SEEPAGE PIT (� Depth v<g.. _._... Diameter �J--.-__. Number . ............... Rock Filled' Yes,j� No !' . f4i Water Table Depth _. yi`/..._' .....:...............Rock Size'--._.,-?................. M ..p r t Distance to nearest: Wel! _......-.--�^"" ,-:"""- --------!= Prop. Line: �1................... � REPAIR/ADDITION(Prov. Sanitation Permit# ............................................. Date ---.------_---..-.--.----.......1 f Septic Tank (Specify Requirements) _..----------------.... DisposalField lSpecify Requirements) ................................................ ....... .......:................................................... ............... . . --- . .............. -- .----E: ..----.... ........................,._._.................................... (Draw existing and required addition'on reverse side) ' hereby certify thatA-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. Horne owner of )icon- 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 .:.. .. . . .......... .... ---------------. -- -------- Owner r By .... . .. .......... .... . (I er than owner) FOR EPARTMENT SE ONLY -'' APPLICATION ACCEPTED BY ..._. w G'1.��° 1 .... .. ......... ..._.._.... --• ---. DATE -- . - .�Q... . BUILDING PERMIT ISSUED __.._..,___•................ 3 --------•---•------ - --••- --------------=- DATE _...- ' ADDITIONAL COMMENTS .............-..- ---.------------------------------------------- ---- ---------- ---••-• -----......._............_,-.-..-.-.-...----_..•---.....•. .----- --------._....................._....-.-..._.-.._.._......_......._.._............_...... ............. ---------- ..-;........------. ----- -- .................-----................... ......... ............... ........... ....................................... • . . --- / _ Final Inspection by: .._ •----- ------Date --- ~ SAN JOAQU LOCAL HEALTH DISTRICT fC�