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MIK Urr0..L wc: APPLICATION FOR SANITATION PI R ------•--------------------------------------------- -•---------•--...--•..............- - - - -- � � Permit No. 7�:.7_.� (Complete In Triplicate) This Permit Expires i Year From Do»Issued Date Issued .6:."T.....�/'. L 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/mad�7e in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/ OCA N F?_-�11�....��Q ....�F2.Gt !' ..................................CENSUS TRACT .....----•.-............. Owner's Name __..L/0-1-L". an........Q. .-•...................... ..--............................Phone JKk-.rp..9. - -•---- Address ... _.......... fr Contractor's Name . 4��1']d s G/....1 ... ............-.......License #7:�q"3.4b..... Phone Installation will serve: Residence 0 Apartment House 0 Commercial❑Trailer Court Q Motel ❑Other............... Number of livingunits:........_ Number of bedrooms --- . .....Garbage Grinder ............ Lot Size ................4-.Z. Water Supply: Public System and name - ------------ ---------------...-_..........-_...................._....._....Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Gay 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 seepage pit permitted if public sewer is available within 200 feet,) LPACKAGE TREATMENT [ J SEPTIC TANK ^ ��ize..........51 )Cj�e...... ........ Liquid Depth .. � ...it............ . Capacity�Y70 Type . t..... Material...(.. No. Compartments ....a'........... r Distance to nearest: Well ...._..7� . :}.................Foundation..../� �y....... Prop. Line .. ..�I'._..... �. LEACHING LINE [� No. of Lines ----- ..�............ Length of each line._......`0...._..-- Total Length .._.1. ............. �� ,99 n D' Box .....t✓. Type Filter Material .....Depth Filter Material .....1. ............................... r Distance to nearest: Well .......SV.'I ..-- Foundation ... .. ........ Property Line .:%.................. SEEPAGE PIT Depth ....-fes......... Diameter ----- Number ...........r.... .._..... Rock Filled Yes No I❑ Water Table Depth ................................... .........Rock Size sj'f".XIi ----��------- Distance to nearest: Well .......IlAa....±.................Foundation ---/.Q.--±f ... Prop. Line ...rY....f'...... REPAIR/ADDITION(Prey. Sanitation Permit# .............. Date .......................-.........I SepticTank (Specify Requirements) ... -- ................... ...... ...................._.............................................--...... ----------- .......... Disposal Field (Specify Requirements) •.... ............ ............. .........................I...................... ............. ---•------------- .................. _.......... ---------------------------------- . ..........................-.... ......................................................••-.......................................................... . - _._.... --------------- ------- _....- ...........................-_.._ (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that the work will be done in accon[ance with San Joaquin County Ordinances, Stale Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "1 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 Workman's Compensation laws of California." Signed _. . - -------- ---------------------------------------------- Owner BY - ,� � :�..............................- Title ...._. ......_._ __. _._......__......_. (If of than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ......e -. . DATE Z.. . ., BUILDING PERMIT ISSUED -- - -.... ...._.... . . ..... . ---- ..... ----- ......_..............DATE . .._ ._..................... _ ADDITIONALCOMMENTS ..-.......... ..... ................................................ ...._.__.-.._ ...................................... _.._._.. . ..........._......... . ...... ---.............. - -------- ..........----......-_._................ ................... -__..... . .._. ................ _......_..._..... -............................................ ._ . ......................................... ------------------...._.._--.._. -- - ....... .......-- ............... - ........-._...... -- .....__..1..._. . - - . ... FinalInspection by: ............ ... ..r - ----- .. .....------------...............................----------------- Date ...w'.. h .0 r....._. .._�.... _................. EH 13 21♦ 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7lr .,3M