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FOR OFFICE USE: APPLICATION FOR SANITATION P IT `— (Complete in Triplicate) Permit No. __6.9-401 ----------------------------- ------ pp --------------------------- ---------------- 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 t work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules an ulations: JOB ADDRESS/LOC N .� d �_..'//,_ r_ _ -..._-- -......_.__CENSUS TRA -- ---- .........---- Owner's Name ..�ate-- �rr'�a^t' `' - ---------------Pone ------------- Address ------- PS-e -�` - ' ✓^ C'� ` Contractor's Name .----1��x.r.�--�--- ---- --- �, _ ..tlicense # --i-8��X.Y- i'hone ....-----_-------------- '--:artment will serve: Residence Apartment House Commercial ❑Trailer Court fl Motel ❑Other ___.._._.- Number of living units:------- Number of bedrooms ___Garbage Grinder ------------ Lot Size ___10-e ms_....------- Water Supply: Public System and name --------------------------------- ----------------------------------- --------------- Private Character of soil to a depth of 3 feet: Sand E] Silt F] Clay EJ Peat E] Sandy Loam [Clay Loam 0 Hardpan ❑ Adobe 0 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,) U PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size------------------------------._---...__-__-__ Liquid Depth ------------------ Capacity .._....__--_-.Capacity Type -_--------------- . Material-------_-----------_- No. Compartments -------__........... Distance to Aeacest: Well _ _ --------- -- -------Foundation ----- Prop. Line --------------- -- °� LEACHING LINE [ ] No. of Lines ------------------------ Length ;of each-line- __ 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 SepticTank (Specify Requirements) ------------------------------------------------------.-------------------------------------------------- ----------------------- Disposal Field (Specify Requirements) .---_ .J-_ -_._ -� __0? ...... ----------_- ---------- ---------------------_ -- ------------- --------------------------------------_ -------------------------------------------- ------- --- ---------------------- (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 ermit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of alifornia:' Signed - - - /EPARTIMIENT ---------- Owner By - ------------- -t�fLvG u*---t5/---- -------- Title --- _6lle1 (if other than owner) FO USE ONLY APPLICATION ACCEPTED BY - -- ----------- --------------------------- DATE . -lJ---6 ----------------- BUILDING PERMIT ISSUED ------------------- ----- ---- ------------------------------------------ --- --- --- -----------DATE ------------------------------------- -- ADDITIONALCOMMENTS ----------- ------------------- ------------------------------------------------------------------•---------------------------------------------- - --------- - ------------------ - - ' - ----------------- ------------------ -- -- -- ----- -- (y_ - - s{fj ------ - q - �'y 7 Finallnspedionby -- -�----- -- ------------------ --------------------------------------*'.Date --"------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT M c u o i_'AD D„•, KAA