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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT — (Complete in Triplicate) Permit No. __________________ ---------------------- 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 N 549 and existing Rules and Regulations: .,L Y/1l , JOB ADDRESS/LOCATION ._._ ----l�J_�o-/�------�------L__�1DIf Y1- --- ----------------------CENSUS TRACT ------------------------- Owner's ---------------- ----_Owner's Name -----to- yn-------- ------ ---M hone Address -------------- _.Ly- u - `7��' ---------------- Cit Y --------------------------••-•---••------- Contractor's Name _ �a C ��-c }"'i`G T4.A_K._CO—.License # _ -1 /--- Phone Installation will serve: Residence [Apartment House ❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other -------------------------------------------- Number of living units.--__J----- 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 [X Fill Material _.__ ------- 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,) PACKAGE TREATMENT [ I SEPTICT�K Size-________IAa_ &________________ Liquid Depth ____,�' __________ 6 Capacity "'"�ti2------ Type _ _ _ MaterialNo. Compartments ... .... ........... Distance to nearest: Well _____________c y0____------------Foundation 10----------- Prop. Line _____ -__-________ r LEACHING LINE bd No. of Lines --------I g O -___ Length of each line.________ __l-�____._____ Total Length __, �.D___.________ 'D' Box .___�---- Type Filter Material ______A__f"__--Depth Filter Material _______-_ !---`______________________ Distance to nearest: Well --------- .1---__ Foundation _____ ______ Property Line ------7_1: ........ ' SEEPAGE PIT Depth -------------------- Diameter ________________ Number ----- --------------------- Rock Filled Yes ❑ No �❑ Water Table Depth ---------------- Q- ----_, �` --------Rock Size ------------ --- - ---------••--- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line •--_-_-____-____-_..._ p REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date -______-_________________....____) i Septic Tank (Specify Requirements) ------------ - g: -------------•----•----------------- -- .. --_ Disposal Field (Specify Requirements) --------- HCl 0 -' -Ra-------------------------------------------•---•----------- a - - - - - - -- - -------- ------ f Draw ----fDraw 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: 1� "I certify that in the performance of the work for which this permit-is issued, I shall t employ any person in such manner as to become subject to Workman's Compensati6n laws of California." #" Signed ------------------------------------------{ ---------------------------------------------------- Owner eee BY ------------ -------------- Title - - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY '-ems-- -- -------- -- --dY��--a --- ----. DATE --- 0 BUILDINGPERMIT ISSUED ------- ------------------------------ —• ._. '--- ----------- --------------DATE ----_--------I---------------------------- ADDITIONAL COMMENTS ::- ---------------------------------------------------------------------------- ------------------------------------------------------------- -------------------------------------------- Final Inspection by- --------------- Date 's - SAN 4Q - UIN CAL HEALTH DISTRICT Y` E. H. 9 1-'6B Rev. 5M