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FOR OFFICE USE: PLICATION FOR SANITATION PERF` ) ....... ...... ------ Permit No. ... _ ... (Complete in Triplicate) ...... ...................................'__..---. This Permit Expires L Year From Date Issued Date Issued ...7=1 .-� 13 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 }�.. CENSUS TRACT .....---..........--...... Owner's Name °�f�cz,:�1, .• �•S� ... .. .....Phone . �-----� d�°Eas.t �.:�._.-��...... --. City ��?Wt)�� Address ............... .. ................................... Contractor's Name ....----- _' fF - ?�._7- ! :.............. ..License # ` 3. ��..... Phone .- .6f.?A° ... Installation will serve: Residence ❑Apartment Houseq Commercial ❑Trailer Court ❑ Motel ❑Other ---- 4_1 Number of living units .:.:_.___ Number of bedrooms _2�......Garbage ,Grinder ........Lot Size . d�.__..K.J.�a......._.. .3..._._.::: Water Supply: Public System and name ....................................__.....----- ;a -•-•---=....:_.................................Private Silt Clay Peat `�- _. _..._. , . Character of soil to a depth of 3 feet: Sand 0 ❑ y A ❑ � Sandy Loam ❑ Cloy Loam ❑ Hardpan ❑ Adobe❑ Fill Material ............ If yes,type -------------- ....... (Plot plan, showing size of lot, location ofsystem 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 [ ] SEPTIC TANK ] Size._ -.- _ __... ....._._._ ..... Liquid Depth•...-� . ...... - Capacity ._.•-- Type ... a .� No. Compartments .... i Distance to nearest. Well .......4�.4??__..........._.......Foundation ...>b.r ....... Prop. Line ....ar... �._..--�.r LEACHING LINE [ j No. of Lines :.__.._ ___....... g .. ....i�Z_Depth -- -� .......... Total Length 9.1Q.............. 'D' Box 1 Type Filter Material of e Filter Material _.Ag................................ Distance to nearest: Well ...... Foundation ....._.1Q r. ...... Property Line ..0 .. .............� SEEPAGE PIT [ J Depth -------------------- Diameter --------- Number ............................ Rock Filled Yes ❑ No CE Water Table Depth .... ........._..:.......Rock Size ................................ C Distance to nearest: Well...................'.............. .......Foundation .................... Prop. Line ..................... - REPAIR/ADDITION(Prev' Sanitation Permit# F ...................I....._...........:_:.._. Date ......................._..........I W Septic Tank (Specify Requirements) -------------------------...................:...............------•..........•-•----............................ --------------- Disposal Field (Specify Requirements) ....................................................................................... ..•------ ------------------------ •-----•-------------------- ---------------------- --------•-------.._...••-----•-•--:.------•-•--....--•--- ............................................................................... (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 District. Home owner or licert. i 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 become subject to Work an's Compensation laws of California," Signed ---- ---- - - ---- - ---------- = -----------•-- •---------- Owner If other than owner) ) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ... ._.._ .. ......... DATE ....... 3 - -------------•-• -•-•--••------•-------------- --- BUILDING PERMIT ISSUED ... .... ............................:................................•--:__........---..:..............DATE ........_................ .... l ADDITIONAL COMMENTS ....... ....................................................................... ........................................ ..... -------- -------•----- ------ •-----........... ........... -• .......- ........--- .........--•-•--•--------- .... . ............ ............. Jw� ....Date ... ................Inspection by_ _________________ -••----- ----- -------------•-------•-------------------- ............ . L L HEALTH DISTRICT SAN.JOAQUIN C►CA -