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FOR OFFICE USE: Y� APPLICATION FOR SANITATION PERMIT F�w [Complete in Triplicate) Permit No: y_: --- ------ ------------- -- ------------ ----- - `"" Date Issued __� /7 ----------------------._._______ This Permit Expires'],Year.Froin Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work- herein k des'cribed. This application is made in compliance with County Ordinance No. 549 and existing Rules anRegulations.. JOB ADDRESS/LOGATION� A3- --L�'r.--�i�l c1 �px�.c� a� -jj G��SUS TRACT -- --- -- --------------- Owner's Name `L/ - T/_6 ---------------------� JPhone d /r-= Tr— Address ----------- -------- ----'----.----- C12�_P,_,�-------------------------------------- --. City ------f ---------------------------- Contractor's Name ------------ -------••f4-"7&-----'--------------------------------------License # --------- ------ Phone -------"----------------------- Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court I�/ d��C� i tv Motel ❑ Other ----- -------------------------------------- Number of living units:_____-- Number of bedrooms - ___Garbage Grinder .__._.______ Lot Size _______________ Water Supply: Public System and name ------AyW✓�___ Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Siff❑ Gay ❑ Peat❑� Sandy Loam - Cray'Loam-❑ -�- - Hardpan [] Adobe ❑ 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 seep a pit permitted if public sewer is civ ilable i hi 200 feet,) �� W PACKAGE TREATMENT 7 uid Depth ---------- --- -•---•--- a ,�. [ � SEPTIC TANK�[ � ,�Xq � -�.3 W 01 Capacity - ype -�-- Material_ No. Compartments Prop. Line -- istance to nearest: Well _ - --------------------Foundation _ _ - -- ----L------ LEACHING LINE No. of Lines -------- ------------- Length of each line__-_.Q4:e_--�----- Total Length -- -rT .-- D' Box ------_____- Type FilterMaterial _ _ GDepth Filter Material --------Ap----------------------------- ' Distance to nearest: Well ___ �______-__ Foundation --- Property Property Line_ ____r SEEPAGE PIT [ ] Depth _.________-__._____ Diameter ___________-__ Number __-________----------------- Rock Filled Yeso i❑ Water Table Depth ------------------------------------------------Rock Size ---------------------------•---- istance to nearest: Well ----------------------------------------Foundation --------------------- Prop.;Line _---------------_.._-- REPAIR/ADDITION(Prev. Sanitation Permit# -------- -------------------------- -------- Date ---------------------------------_) Septic Tank (Specify Requirements) ---------- Dispos Field (SpecifyRe uirements) --------- 1 ------ +�- tD + i v f -------- ° - .--- "--- ---- ------ _ (Draw existing and required addition on rev se side) I hereby certify that 1 h e 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 Disirict:Homeowner or ficen-----qj sed agents signature certifies the following: "I certify ththe performance of.the work for which this permit is issued, I shall not employ any person in such manner as to bec me s j ct tow m -Com ensation laws of California." --- Signed --- ------ ------ 7 ---- --------------------------- - Owner BY ---------- -- - -------------------- ----------- -------- Title --- --------------------------- ---------------------------------------- ---other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ ------ -"---------------------------------------------- ------------------------------ DATE �7 BUILDING PERMIT ISSUED ------------------ - ---------------- --- =' _- DATE ---- ADDITIONAL COMMENTS ------------------------- `' - '' '- ----------------------- --------------------------------------------------- ----------------- ---------------------- ------------------------------------------------------ ---------------------------------- f ------------------------------- ----- ---- - - ------- ----- - - - --�--�--^- - - --- Final Inspection by: - __ ._._ ------------------------------- ---------------------------------------------- - -------.Date U__.____- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M - f