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FOR OFFICE USE: N,tICATION FOR SANITATION P91M1`,i ' (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 No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .fz�l .y._�I,/L�1�..LhO.S. -tPO-------- .........................CENSUS TRACT .--------------------.- Owner's Name _.! LV [ .........6!,_...... .S lei----_--------------------- •--•---•-•-----Phone ----------------•__ Address ----- City --`------------•-------------------- Contractor's Name -!h`- 6:'E.•- -------5 '----------License ' � Phone _-------------..._.___.. Installation will serve: Relidence Q'Apartment House Commercial❑Trailer Court I] Motel ❑Other-._..-----------.--------------------- ` Number of living units:-_-/_------- Number of bedrooms _a9____Garb0ge Grinder/U�._. 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 0 Hardpan ❑ Adobe ffFill 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 [ J SEPTIC TANK Size..........._.._.............. _ Liquid Depth --.-.___--__.-........ Capacity 4?Vd--,•-- Type iOff6L__ Materia[. 60_&.t_ 60:_Nc. Compartments Distance to nearest- Well .......................Foundation ---AC.............. Prop. Line LEACHING LINE [ j No. of Lines -----/................ length of each line------170.1........... Total length ,__-9D_� 'D' Box ASO.-.... Type Filter Material .16O ----Depth Filter Material I Distance to nearest: Well ---;:b:-_.-.._.---- Foundation .....�Q- _...___--- Property Line __.. e��_-------_- SEEPAGE PIT [ ] Depth ._e�./---..___. Diameter ...x.:3.7__ Number --------�___-_-.._-_-_._ Rods Filled Yes ['J" No 0 Water Table Depth -----------------------------.__..---.-_--__..Rock Size ._.... ------------------------- Distance to nearest: Well ./.�---_-_-____--__-_-----_Foundation ....1�_..._..__. Prop. Line _.--�--_-_._____- REPAIR/ADDITION(Prev. Sanitation Permit# _-........._.------------_------------- Date ___-----------------_.._----I Septic Tank (Specify Requirements) -..--•----•-----•----------------------------•----• -------•---•-----------------•--••-•-•--•---•-----------•------ Disposal Field (Specify Requirements) L --------------------------------------- ------------------------- --------------------- --------- --------------------------------------- -------------------------------------- --------- —----- -•---- .....------••----------------- ---- (Draw existing and required addition on reverse side) 1 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 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 becomeub[act to Wor en's01A mpensadon laws of Callfwalla." Signed .. ..................-.................- Owner By ......----------- -------------------------------------_•---------............................... Title .--------.----------- -- ----------------------------------- ` (If othjtr than owner) EPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- --- - - ------------------------_ ......_ ------------------ DATE __/,1:��'e ----------..------ BUILDING PERMIT ISSUED - ----- -- - ---I---------1-------......-------------------------------DATE ADDITIONA COM TSS.... -. --- -... ........ •-•---.. .-•- -• --- "� ------- ------- - <�...-- n...�r .1-.- �,u...._.�..- �v r/4�j9*+% olr ayk' 6•v . �1� - __. 1 ...........................---------------------------------------__----_.. -_._-__----__-.e.-._. - ----- --------- - - -- -- ----- ---- - ----------- Final Ins ection b _ .._.Date ---.� L02UIN LOCAL HEALTH DISTRICT r W 0 1_'/.R 0." SAA