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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------- Permit No. (Complete in Triplicate) - - _--_ This Permit Expires 1 Year From Date Issued Date Issued ---._--_--__-______________________ Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application lis a e in complia� with County Ordinance No. 549 and existing Rules and Regulations. 1pv JOB ADDRESS/LO ATION ---- --------- _f `s_CI" RVI CENSUS TRACT Owner's Name -----------------I Ae"_ ter------�/�'� � iq-------------- - ---------------Phone I ° ,�✓ Address - L^1• ! 1 ------------- City LTJ-�/1 - Qat - --------------- _ Contractor's Name�)6_0__ �rc��---�-�: - t-C � _� --------------License # _ :6t .� �____ Phone Installation will serve: Residence PRApartment House❑ Commercial :❑Trailer Court !,❑ Motel ❑Other -------------------------------------------- Number of living units:-------- Number of bedrooms --...Garbage Grinder ------------ Lot Size ------------- Water Supply: Public System and name ---------------------------------•----------------------------------- -----------------------------------------Private [ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ' Hardpan ❑ Adobe•4 Fill Material ------------ if yes,type ---------------------------- (Plot plan, showing size of lot, locaiion 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 isavailable within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK f f Size------ �' �'ft1------------------ LiquJd Depth Capacity -f_ r---- Type __ ___-__- Material_e_,aydf>fV__ No. Compartments ---�_--....------ilb 4 Distance to nearest: Well ------------ '`-_--___Foundation --/62_x---.--- Prop. Line ._ --------- LEACHING LINE No. of Lines --------2----------- Length of each line------- ------ Total Length .-11-�-...... --•-�•-•-- 'D' Box ___ ------ Type Filter Material_-_-- _��------Depth Filter Material -___-__/__ _______ ____ __________ Distance to nearest: Well ----- ---- ---_ Foundation _--_ --____-____ Property Line --- ................ SEEPAGE PIT Depth ----- ------ Diameter , -------- Number .......�_----_--_--___ Rock Filled Yes No i❑ Water Table' Depth ------------- ------------------------Rock Size ------- ------------- Distance to nearest: Well ______/� --- -------------Foundation ------—------ Prop. Line _._.,/ _ ....... i REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----.-.---------------------------) i SepticTank (Specify Requirements) ---------------------------------------------------------------- ----------------------------------------------------------------------- Disposal Field (Specify Requirements) --------------•-------------------- { -------------------------•--------------- --------- i 6---------------------------------------------------------------------------- { (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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed --- ------------------ Owner ® --- BYt -- --------------------------- Title ----- - --- _�__'� ..-------------�--------------------- (If other than owner) ' �r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------------------- ------------- DATE -------I .tel-e_7 -------------- BUILDING PERMIT ISSUED ------------- i. - ----------------------------------------------------------------------DATE -- -------------------------- ------------- ADDITIONAL COMMENT - • --- -----------•---------------------------------------------- ----------- --------------=--------------------------- i�---�`-7 t-------------- ----- ---- -- - ------------------- ------ - - --------- - ------------------------------------------------------------------------------------------------------ ----------------- ----------------------------------------- - ------ - ------------------------------------------------------ -------------------------------------------------- Final Inspec#ion by: ----- ------- = - ,-- - ----------------- ---- ----------------- ---------------- Date --------------- JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1 '6B Rev. 5M �