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FOR OFFICE USE: 1; y / I+4 3 ° 4PPLICATION FOR SANITATION PER"tT _ /) 44 . - - -- - -�- � Permit No. r�--__ __...�r57S..N1 (Complete in Triplicate) a / ------ 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 No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION /f S.T _-FI_.CE/1A�fN —CCA,eNA-tYO .........CENSUS TRA,/C/T/ ._-------------------- Owner's Name -�ICr�r� D-AJ'. cop.--- a----0-M&S-e- BL,0V.A4....Ci0--- - - ----PhoneF-fl�U� Address �� TrJ��9L✓--------- City -- Contractor's NameG4-Wil$-�{----- ---SII-/11-5_----------_-------.License # -�./----- Phone �Y�Q.t/G-r(-�/---P -.-- Installation will serve: Residence ❑Apartment Houle,❑``Commercial Proiler Court Motel ❑Other Number of living units:-- ... Number of bedrooms ---_------.Garbage Grinder ---- Lot Size ----- _ --------------- Water Supply: Public$ystem and name --------------------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand E] Silt E] Olay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe X Fill Material ------------ If yes, type __-------_-----.----__. (Plot plan, showing size of lot, location of system in reilation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit p@rmitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTICTANKr Size_)(1_ . ---- -__---------- Liquid Depth .- Z.��.___..-- Capacity/1VO Typ --.-- -- -- Materiall "qpw�G�C. �No. Compartments �?e ---.--...... Distance to nearest: Well _F�- .-y�-_--__;..----Foundation _Zs FT-- Prop. Line _e16 LEACHING LINE [ ] No. of Lines Length'of each 'line_. Total Length krQ_. f;?.0 It jO ''�� - 'D' Box ._r��- Type Filter Material' �y- --Depth Fi ter Material 1,811------ ......................._- Distance to nearest: Well 1Sp0-N.E------- Fouddation .,,5 .___. Property Line _ 67--�----.-.--- SEEPAGE PIT [ ] Depth .. �_- Diameter _ - ��-_- Number ..�7z.. ------------ - Rock Filled Yes [}� No ❑ Water Table IJepth -.-7.4_. --- - :.,.:i----.Rock Sizef y-----LV-----------=-_4 ... o 0 Distance to nearest: Well --------------Foundation Prop. Line _-S.._ --.. REPAIR/ADDITION(Prev. Sanitation Permit# ---_I-. -----,-_-- --------_-,5-- -- - - Date --------- --.__--._------------) Septic Tank (Specify Requirements) _ -- -----x"' Disposal Field (Specify Requirements) --------.i---------------------- -------- ------ ------------------------ ----------- ------------ -- ---------- -±`-------- - - ---- --- -- - ------------------- - - - -- -- ----- --- - --------------------------------------------------------- re - ---'------------ -: (Draw existing and required a ddmQn on reverse side) I hereby certify that I have prepared this application and that khe 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 w ich this pern4t is issued, I shall not employ any person in such manner as to becom so ect to_Work n s Compensatio aws of CalifoOnw." Signed - ------- - ........ - - - ---- ---- - -- Owner By —�-Lt-d l�"4 =: -_ Title :.._,:. (if oth r than owner) { FO EPAR NT UUSSE"ONLY APPLICATION ACCEPTED BY ----------- ------------- DATE --- - ------_------ ----; BUILDING PERMIT ISSUED - - --- -------- - - 1- --- - -DATE - - ADDITIONAL COMMENTS -------------------------------- ------------------------------------------ ----- ---- ----------- --------- - t`---- - - ------------------------- -------- 4 W _...------ - -------------- — - ---------------------- ----- ---- f--- - ------------------------------------------ - -- - --- r }�� Final Ins ection b n/V- -- ."'l------------------------------------------------------� ---------- ------------------Date J - 6 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6B Rev. 5M