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FOR OFFICE USE: APPLICATION FORSANITATION PERMIT 3 .-------t------------ •-----------. . (Complete in Triplicate) Permit No. .'-3- _S.___ ]-- 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 the work herein described. This application i made_ in_-compliance v�h County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS LOCA I --.- ---gin -�"' .._.. �1 1-�-r�. ----- RD------------------CENSUS TRACT - - -5 ---- y . Owner's Name ------wo4.L�.S....... - _jqW_& �--------------------------------------------•--------------------Phone ---------- ......................... Address ------------1-1-/-------- t-►�A/1 .-----• ....... ------------------------------ City --._RJi�/V_ ------------------------------------------- - Contractor's Name Q W/1 ER ----.License # ----- ------------ - Phone ------------------------------ -- .. Installation will serve: Residence Jlpartment House❑ Commercial ❑Trailer Court :❑ Motel ❑Other -------------------------------------------- Number of living units:------I.... Number of becirogms ,_:.Garbage Grinder Aa--- Lot Size _._.�LAE/T_6 -------.--- Water Supply: Public System and name ---------=------------ -----------------------------__---------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam e Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material _1 Vk If yes,type -..____------_..__--_-_-_- 0 (Plot plan, showing size of lot, locatio of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic to seepcipj pit permitted if public sewer is avail ble within 200 feet,) PACKAGE TREATMENT [ ] SE i Size________________________________________ ______ Liquid Depth .......................... Capa .--- -.. terial-----__ -__ No. Compartments ...................... Di f _...._.Foundation __-. ----------------- Prop. Line ..................... LEACHING LINE [ j n f each line-------__.----- ---- - -__- Total Length --_------------------------ ox I --------------------Depth Filter Materiali----------.................................. to I -- ----------- ------ Foundation ------------------------ Property Line --------- .............. SEEPAGE PIT [ J Dep -------------- ---- DiarT eter ---------------- Number ------------ ------- ------- Rock Filled Yes ❑ No i❑ Water Table Depth ----- ----------•-------...................Rock Size ------- --------•.--------------- Distance to nearest: Well ..................................Foundation _ _.__.. --- Prop. Line ---_..._--.---_.--__-- � REPAIR/ADDITION(Prev. Sanitation Permit# ........ .................................. Date -----------____ __.___---______-) SepticTank (Specify Requirements) ----------- ------- ----------,--------- -----------------------------------=- --•------•---------- ---------------- ---------------- Disposal $geld (Specify Requirement) _ ._..._ _ _____ ____- (Draw existing and required addition on reverse side) I hereby certifyJlzet I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinancet,,,,State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signaturecertifies the following: "I certify in pe o nc of the work for which this permit is issued, I shall not employ any person in such manner as to be e s A to k n Compensation laws of California." Signe _4---------- ----------------•--•----.----•-•-----•------------------- Owner By ,. ----------•---------------------------- =---------------------------------- -------------------------------•- --c- - C�, ...._ Title - -- ----•--..........-----• (Ifkother than owner) FOR DEPARTMENT USE ONLY AQLICATKXAAtCEPTED BY ------•- f I BUIt t ..r.._,.t ------------- DATE -------�� _ ADDIWAAL COJk MENTS --------- ---------•----•-----•---....- -------`-------••-----••-----•------------------ ................•---..__.........---------------- -------------•---------------------------•----•-•------------•-------- ------•------ ----•---------------------------•-----------------------••----•--- --------------------------------------------- -•----------------•----t--------------- ------------•••----•-----------••-------- --------------------------- ---------- ,:--- -• Final Inspection by: _----------- - ---.Date ----•-� r------- ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.•9• 1-'6&.Rev. 5M CD,