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4 k FOR OFFICE USE: APPLICATION FOR,SANITATION PERMIT �/ A Q Permit No. -./ -L��1-_� (Complete in Triplicate) ---------=------ ------------------- -------------------- P Date Issued _/----.� This Permit Expires 1 Year From Date Issued - 1 ' 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. 9 and existing Rules-60 Regulations: r �f e ,�---------CENSUS TRACT -------- JOB ADDRESS/LOCATION .- _ _ ---� .f-�I � - Owner's Name ;------ -A-----s _?--- --------- ---Phone ''// ,��,f---Pho -of,3_6_ AJ----- -fi-YwN�_J. City �a-"'�--------------------- ------ - Address -------- ------- ----= --------- ---- Contractor's Name ----- --------IC�•cLgEz-7-- ------------------- ---- {-.License # l y - Phone -- ----- -_- Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court l❑ Motel❑ Other ----- ------------- ----------------- Number ----- --Number of living units:--_- Number ofdrooms --_-'_ -----Garbage Grin i3r ':'Lo`t Siie:� Water Supply: Public System and name LIC I --- -t -------.Private El Character of soil to a depth of 3 feet: Sand'❑ Silt❑ ;� 'Clay, Peat❑ Sandy Loam ❑ Clay Loam El Hardpan ]] Adobe Fill Material ------------ If yes, type ---------_----------------- � IPlot 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 [ ] SEPTIC TANK f[,] Size------------------------------------------------- Liquid Depth -------------------------- Capacity -------------- Type ------------ _----- Material--------------------- No. Compartments --------- , 04 F si Distance to nearest: Well -------------=- -\=----- ------Foundation - :-- Prop. Line . LEACHING LINE [ ] No. of Lines ----------i------------- Length.of each. line-----.-----_-------------- Total' -Length :_----.---.:-...--:..... - 'D' .Box ------------ Type Filter Material ----------i_-_ 'Depth Filter)Material --------I-_rlf--'"-------------------------= r Distance to nearest- Well ---------------- ------- Foundation ------------------- Property; Line ---------.--.__..-.......r ► _ ` --- Rock Filied Yes No .�„ SEEPAGE PIT [ ] Depth ------------------- Diameter -------_---_---- Dumber _-�. ---" =.------- p Water Table Depth ;---------------- ( t Rock Size ----} 7 ----------- Distance to nearest: Well ----------------------------------_--- _Foun.dation --------------- Prop. Line -----••--------------- J Date -=-'---•----- --------------------- REPAIR/ADDITION(Prev. Sanitation Permit*---------------------------------------- ) � Septic Tank (Specify Requirements) ----------J---------- -- i ----------------- ------------.. r es �V4/ ---- Disposal Field (5pecify Requirements) + - --- r ----t- ------- - ----ter------------- ----- ------------------ ------------------ ------------------------------------------- . (Draw ex,isting,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: "1 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 By ------------------- = ----- --------- ------ Title ------------' "` `� ---.:-- --- (If ther t an owner) { FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY {f '° - - DATE -. ,I-�f I7� ------------------- BUILDING PERMIT ISSUED ------------------------------------------------ ----------------------------------------------------- DATE - ADDITIONAL COMMENTS ------ - ------------ --------- � ` -------------------------------------------------------- ----- - - - - - - - --------- ------ ------------------------------------------ --- - ---- ----------------------------------------------------------------------------------- ---------- -- Final Inspection by: -.- .- - ---------------------'------ --- Date = SAN JOAQUIN LOCAL HEALTH DISTRICT ` E. H. 9 1-'6B Rev. SM '''-