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FOR OFFICE USFt V ...... ............. •..•... APPLICATION FOR SANITATION PENT, Q .. I - � [(\vJ�J tur P it No. . (Complete In Triplicate) Date Issued .....................•__•._____-__•,_,...- ............ This Permit Expires i Year From Dalssued te 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/LOCAATION ..I SP .....�........tAA.t T .• ..:..vbt�v.# ao . ........CENSUS TRACT .......................... Owner's Nome .!/.St iQe S.-. .4�y..A�.¢oft r' ✓r-5..............„..................v.. ........_.....Phone .9.$.sd,1155i ........ Address .......... - --.. ---__,City .......... ...... ....q... ............... . .._.. ....... Contractor's Name ..A-.. `-�......_.b.pxc,1r'F(O rg..:..................................License # 3.�0 .�.�1_..I. Phone .Jr.99..a.9..�.6.. Installation will serve: Residence ❑Apartment House[] Commercial KTroller Court I] 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 ❑ Fill Material ............ If yes,type ............... ............ V (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,) C/ PACKAGE TREATMENT ( j . SEPTIC TANK Size............................:r.................. Liquid Depth ........::::: `....... Capacity ./D-00.... Type C1Ies'4S44TMateriaLST'f'(12ti. T No. Compartments _2............ Distdnce to .nearest: Well ----74 70A ..Foundation ..IS.........•.. Prop. Line ...� ....... LEACHING LINE [ ) No. of Lines _2........._...-:. Length of each line.._I'A ..�............. Total Length 'D' Box ._ Type Filter Material ....................Depth Filter Material ........................................... Distance to'nearest: Well ._.. .................. Foundation Property Line ...................... . SEEPAGE PIT [ ] Depth Diameter ................ Number ............................ Rock Filled Yes ❑ No Water Table Depth ._.......... .. ..............................Rock Size ............ ............ -- -- Distance to nearest: Well ........................................Foundation .................... Prop. Line ................ - REPAIR/ADDITION(Prev. Sanitation Permit# ........ .... ......... . ....... . ..•---• Date ..................................I Septic (Specify Requirements) I -----._-----__------------- --....-------------------------------- --•-•----.............................................�--!J•-.-...-.- -------- Disposal Field (Specify Requirements) 'RGt �=OCa......f�, ISTL^q�.... 59P.TLc...... :H- K ................ S -. Tt!9N 7-0 4V.&..... D.11 _ ... ........NftW.......T . i ...z-... 3� -- - l.cN.ti/.1f=5, - 5AN124r�......0y?.......SyST�M. ... ._........................... .--(Draw existing and required addition on reverse side) I hereby certify that 1 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 Dlstdd. Herne owner or Ilan- 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 bec1 a b"to jorkman's Colrt�ten ation laws of California.” Signed . .L .... -.^.... � ))�-`` �. ... Owner By ..... . _ . .._... .._ .................. Title.......... .._......................._ ....._ .................... (if other than owner) _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY 7 .R .Q .......SIVAVL— ._............................................ DATE Co - .7F'..._......: BUILDING PERMIT ISSUED ................... .............. .. .... . ................. ... .......... ...__.... ----.....DATE ....... ...... .......... .............. . ADDITIONAL COMMENTS ...... -- .. ............... ....... --............ ............................__................... -----------------................................ .. ---- ------- .- ............. -.. --- ... ....... �1 _ ......Date . . . ........... — ................ Final Inspection by: ... . . . . ....... ...... ..... EH 13 2b 1-6(] Rev. 5}t SAN JOAQUIN LCCA EALTH DISTRICT 8�7h 31'1