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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT W . .-- - � -�--------- Permit No. ..7t. Z 7i (Complete in Triplicate) -- ----�_- - --...__................. This Permit Expires 1 Year From Date Issued Date Issued ... T_7I 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 ._.--SO_ W w,` - ..- CENSUS TRACT .._--------------- Owner's Name .../1�.---&4�_ -------- ---------------------- ------------------------ - ----- Phone -------- _ Address ......61U� _._ - -----------------`--------- ------------ ------------------ City _-�G i�7�jS/-- --------------------_--------- - - `----- Contractor's Name _Ae-5--- ---- �i�/Gf--.-____ ___._.--._._._License # 1��D- - ..-_ Phone Installation will serve: Residence-0 Apartment House�❑ C mmercial❑Trailer Court I] Motel ❑Other-_1170,61: T+1 G-----'--- ,,,, Number of living units:._.-/____ Number of bedrooms __'.-----Garbage Grinder lVQ..- 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 p Adobejo 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,) PACKAGE TREATMENT [ I SEPTIC TANK Pj ----- --------- Liquid Depth _SY"_-_-_____ ` CopacityA-W.4W_ Type/09V_ 057____ Material_ No. Compartments - -- -- -----•-----'---- Distance to nearest: Well ...jam_ -----------_---------Foundation ---------- Prop. Line LEACHING LINE [4 No. of Lines --------/------------- Length of each line._{QQ`_--_________ Total Length _ ..-_____ � Q 'D' Box -/��- - Type Filter Material �t/C.__..Depih Filter Material .� ii________________.__.___._____.. '- Distance to nearest: Well ------_�.�._..---------- Foundation _/d__-------____ Property Line -_ ---------- 4 Diameter __ _. Number _. Rock Filled Yes No SEEPAGE PIT (� Depth _�..�r__ �.� �� -�_-1__-___--_-.-- � Q i i / Water Table Depth ----- lJl7.__-----.--------------.-_Rock Size �2_-.✓-_____---- /a Distance to nearest: Well -----/FIU.____._____.__......Foundation .- .-___..-..____ Prop. Line :__...__ REPAIR/ADDITION(Prev. Sanitation Permit# ----_-----_ -------------------_----_--- Date -----..--------------.--------.---) SepticTank (Specify Requirements) ------------------------------------------------------------------------------- ------- -------------- ---------------------- Disposal Field (Specify Requirements) --------- ---------------------- -----_----------------- --------------- ---------------------------------------------------- ` (Draw existing and required addition on reverse side) I hereby certify that I 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 become subject toAarkc,"' mpensation laws of California." Signed ------------ - ..c ------ .....a - -- --_Ca_i---- Owner Byc- --- -- - - -- - - - --- - - -- Title - - - - - ...__ ------- -- - er ih FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - ------- I �-- ----------- - ---------------------------- DATE ----- --------. BUILDING PERMIT ISSUED -- -- - --- ---------- ... - - - — ------------------------DATE - - - - ----------- - ADDITIONAL COMMENTS ------- -- - - - -- - - - ' -------- ----- -------------- - - - ----------------------------------------------------- - -- -- - -- - - - - - - -- ... ..... -- - - -- - - - - - - ---- - - - - - --- —! ��- --� ---------- -- _ - --- . -- ----------Date - -------------------------------------- --------- -I � -- Final Inspection by: -- -- - - / --- --- - - - ----- -- -/- - - SAN JOA UIN LOCAL HEALTH DISTRICT F W 0 1 'AA D.... SAA