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FOR OFFICE USE:,� } :APPLICAT[ON FOR SANITATION PERMIT r dti -°+�`� Permit No: - = 7a--- -----------------' 1r.a� .w�. (Complete in Triplicate) ix --- Dateilssued -- " ------------- -- This Permit Expires 1 Year From 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/LOCATION 11 -�---- ----- f CENSUS TRACT -------------------------- Owner's Name --------h//Q-------------- -Q�-----------------------------------------------------------.Phone -------------------- ------ (9`✓ -T � / city _-. �/ri Address ------------- - -- ------------------ , , -- -_ 2� Name ---- - ---------------- 11lJ e _ / -------'=-------.License # " _ rt Phone r� ----------- Contractor'sInstallation will serve: Residence �rtment House Commercia11 l ❑Trailer Court i❑ Motel ❑ Other --------------------------r ----- -� Number of living units:.".�._-""". Number of bedrooms _-",?.----Garbage aGrinder ,-O----- Lot Size ��a_"t`-- V ---- I / r r I =1.�. r�� ' `i �'y ---------Private ❑ Water Supply: Public System and name ------------L Character of soil to a depth of 3 feet: Sand'❑' Silt❑ Clay ❑ Peat ❑ Sapdy Loam ❑ Clay Loam ❑ Hardpan ❑ AdobeP��Fill Material -X'—_- If yes, type ---------------------------- k (Plot plan, showing size of lot, location of system in relation to wells, buildings etc. must be placed on reverse side.) 7 -. NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) O r .. PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size--" Liquid Depth ".------------- 4 , Capacity --- Type ------------------ Materia[------"--- -.-- -- No. Compartments Distance to nearest:hWV ll --------------- ---------Foundation ---------------------- Prop. Line --------------- I ----:-------:..------ LEACHING LINE [ ] No. of Lines ----_------- 5--------- Length of each line-------------=- Total Length ------_------------------•-- C �i D' Box .;- -------- Type Filter Material -------------------4Depth Fild?, Material --------------------•--- Distance to nearest: Well _----_- """--------- Founda#'ion Property Line ________________________ j SEEPAGE PIT [ ] Depth ---- -------------- Diameter ---------------- Number _ver----------------------- Rock Filled Yes I] No i❑ } WaterTable Depth ------------------------------------------Rock Size -------------------------------- --------:-_....Foundation - ------------------ Prop. Line ---------------- r Distance to nearest: Welly------------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------------------ Date ----------------------------------) �Septic Tank ]Specify Requirements) -------- ----- - I ----------------------- Disposal Field (Specify Requirements) --------�/- ---------------- �rr� ' --- --w------------ -- - ------------------------ ---------------- - (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 i'acen- [ sed agents signature certifies the-foNowing: "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-'s i Signed -------- - -------------------- ------------- -------_r....- .,._. _.._.. Owner 1. ,..".._._.. �.._. ---------------------- F TitletJ ------ ---------------------------- BY ------------- - ------- ---------------------- ther than owner) r R DEPART ENT USE ONLY APPLICATION ACCEPTED BY -----' -------------------------------------------- DATE Gl/_ 4 BUILDINGPERMIT ISSUED --------- - --------------------------------------- ----- -------- -----------------------------.___DAT.E ----------------- ------------------------- ADDITIONAL COMMENTS -----.---_ i -------------- ---------------------------------------------------------------- ------------ ------------I---------------------- --•-------------------- Final Inspection by: Date - ----------- ' SAf JOAQUIN LOCAL HEALTH' DISTRICT t . E. H. 9 1-'b8 Rev. 5M /