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FOR OFFICE USE: -- ------------ - --------------------- — APPLICATION FOR SANITATION PERMIT 71- ,�� Permit No- --------- (Complete in Triplicate) --__________________________________-____-_______.___ This Permit Expires ] Year From Date Issued Date Issued _.5 .7�_. 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 Qmaade in compliance (with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION _ �?--1 .-�_�G�n _-- _- 'epc -------_-----CENSUS TRACT ___&:_1C(_____________ Owner's Name _ s -- - .a------------------------------------------------- ---- -------Phone ------------------------------------ Address ----- V�---- ------- - ---=---------------------------------------------•--- City --- ---- -------- ------------------------------------------- Contractor's Name ----- -----------------------------------------------------------------License # ------------------------ Phone -----------------------....... installation will serve: Residence ❑Apartment House❑ Commercial ❑ ❑ Trailer Court ', Motel X Other - k - ��. N_� Number of living units:____.___.__ Number of bedrooms ___________Garbage Grinder _____ Lot Size ----95_ °--______________ Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private_] Character of soil to a depth of 3 feet: Sand'❑ Si It Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe X Fill Material N -- If yes, type _____-_____________________ (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 public sewer is available within 200 feet,) f y N PACKAGE TREATMENT Tall[ ] SEPTIC TANK� ] Size_____1_Gi___x �_ ___�d__ _5_b_____ Liquid Depth ----.-7_---_ _______ Capacity 14;10Q_ _ __._ Type Q ____ Material_ __ No. Compartments __e7Z------------- Distance to nearest: Well ______50 -----------------Foundation ____ _________ Prop. Line ___ /_________ N LEACHING LINE No. of Lines r [ ] -----�----------- - -- Length of each line----��---------____-- Total Length ---AQ?--.............. 'D' Box V-0... Type Filter Material Depth Filter Material _____ ------------__________________ � i s Distance to nearest: Well --SO._ Foundation -_� Property Lime ___ _--��________________ r SEEPAGE [ ] Depth __t9___________ Diameter __ _ g___ Number _____-____t________________ Rock Filled YesX No i❑ / I Ir fi i, 'ume Water Table Depth ---- ------------------------------------Rock Size ---c--6---r-�-a`------ Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------- ------------ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------=-------------------•.--------------- ----------- Disposal Field (Specify Requirements) -------------------•------------------------------------------------------------------------------------------------- ------ ------- ------------------------------- ---------------- --------- ---- ----------------------------------------------- --------------------------------------- (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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed -`-�---------- ----------- ----------------------------------------------------------- Owner By2c-----"`. /_,L- ---- �0A- ----------------------------------------------------- Title - ----------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--- - --------- ----------------------------------------------------------------------------- DATE S~r�-------------------------------------------------------- -PERMIT ISSUED --- -------------------------------------------------------------------- ----------------------- DATE ADDITIONAL COMMENTS - __ --- _. .....L.. --------- ---------------------- -- ------------- --------------- _ --------- f1 -- ------ - -------------------------------------------- -- Final Inspection by: Nt- ---- -------------------------------------- -------------------------------Date ------- r-- ---------- ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M C-P