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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - {Complete in Triplicate} Permit No. .......... 5-�_-11. -�--�---� � - This Permit Expires 1 Year From Date Issued Date Issued- .�_ kpplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 'his application is made in compliance with County Ordinance No. 549 and existing }Ruules and Regulations: �iQG JOB ADDRESS/LD TION...._...© `�' / - -- -- -. ..._..CENSUS TRACT i f Dwner's NameGZLL,,4eg5G_ 4�. Phone Address... . - l ± l .. Cityd 11-�-�R�� -- Zip �.�Z�... --.. 7 Contractor's Nam ..._ ..?cam -�}'' License # ,JZ2_ Phone _nstallation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other_ .... Vumber of living units:.... t----- _Number of bedrooms _ 1- .Garbage Grinder___ ..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 ❑ 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.) VEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) --PACKAGE TREATMENT [ ] SEPTIC TANK [A Size_4y�.1x_ !. .d.... LL,, .... .. .........Liquid Depth ..T.... . . Capacity_19b-�-.___Type_. _ Material. _ {ak4--, _ No. Compartments - _ - Distance to nearest: Well.. . . ..._✓r' ........ . ----- FoundationProp. Line {Q �r LEACHING LINE [ No. of Lines __ __ -3-- _-.-- .Length of each line ...... ......... .....-Total Length ... ---- ..... - ----- (�, 'D' Box.... r. Type Filter Material _ P-�-....Depth Filter Material. -------J�/_ _ ............ --- .....` .� i Distance to nearest: Well___..__-�.'f...f.. 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 . .. . ............................} -Septic Tank (Specify Requirements) -------------------- Disposal Field (Specify Requirements)-- __ .. ._...._. ------------------ . ....... ...._-- . . 1 (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 licensed 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 to Workman's Compensation laws of California." Signed............ _ . _ ... - .�� - L . ....... .. .. .... B - ----- . -- - - - ------- ... 1_ Owner r ..-. --(If other than owner) FOR DEPARTMENT USE ONLY o� DATE -.. . -APPLICATION ACCEPTED BY.... � �'.�_lr�+� .:_. �� DIVISION OF LAND NUMBER ......._ DATE .... .... . . .. ADDITIONAL COMMENTS................ .............. ----------------- .. . ......... --------------------------- ---- ----------- --- -- -- ----------- ------------ .. . . ------------------------ ---. - --------- ---- ................ Final Inspection by: �7 � r . T�(j. - Date. .. -FH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT` F&S 21677 REV. 7/76 3M