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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ..................................a= Permit Na. . -723. 3. (Complete In Triplicate) ......... -.............. ................................ Date Issued . 1'..'.... .....7S . ......--•-•.................................. This Permit Expires 1 Year From Dote 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 is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .....94-Ada...... .. ENSUS TRACT .......................... Owner's N me ... .dr •...... .f./QS. J......................................................................Phon ....... .......................... Address ,f7T.[��.) .�. ..... ........ ... ._.City .... �-'....... ,..------------------------ Contractors Name .._ Y. ..................License #,:VZ"a�.l.?'. ._. Phone Installation will serve: Residence ❑Apartment House Commercial❑Trailer Court 0 Mate1 ❑Other 7_� ................. Number of living units:....1...... Number of bedrooms ......Garbage Grinder ............ Lot Size .... .......... Water Supply: Pubtic System and name ........................................................Private Character of soil to a depth of 3 feet: Sand Silt 0 Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom ❑ Hardpan ❑ Adobe❑ Fill M6terial ............If yes,type............... ............ (Piot 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 ( ] SEPTIC TANK f ] Size...... r.X__ X.. .............I..... Liquid Depth --4kV.....••.•••• Capacity ---L ------ TypeV� . MaterialCompartments .... ......�. Distance to nearest: Well ------$FO.......................Foundation ../D..... ........ Prop. Line ..: ............0 LEACHING LINE ( ] No. of Lines ------ ---------_ Length of each IiRe..15fQ........... Total Length�Aa-jO...........4Q•`. D' Box rcxj ... Type Filter Material 1� %_----De Depth Filter Material z..'. p �,.......:.;: r. 1-00 Distance to nearest: Well ./t 0.�.......... Foundation ..-1D............. Property Line -. .....••••. SEEPAGE PIT [ ] Depth .................... Diameter ................ Number ............................ Rock Filled Yes ❑ No 0,- Water ,Water Table Depth ..................................... ..........Rock Size -------------------- ...... Distance to nearest: Well ........................................Foundation .................... Prop. Line ..................... . - REPAIR/ADDITION(Prev. Sanitation Permit# ......._..._................................ Date .................................. Septic Tank (Specify Requirements} ......................................................................I............. Disposal Field (Specify Requirements) ................................. .....................--.•.-••••••. ............................ ••-•-•••.- •-•• --•....--•---•-----•------•. ........................•.-------•---------•---------.......--- --------......._................._... .---.......•.....---•--••--•-----•-•-••--•--•----...._....----........ (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 accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Heatth Olstrict. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work far which this permit Is Issued, I shall not employ any person In such manner as to become subject to Workman's Compensation laws of Californla." � Signed ,u c �.. ............................. Owner c BY ---------------------------- -c.G ............................... Title (If other than owner).. OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- .. ............... .— DATE - ----------- ----— BUILDING PERMIT ISSUED .............. ..-..--.---• •-----........DATE .... ADDITIONAL COMMENTS .............. ....-•-................-1.................... ....... ---.---•.............. ................................................-......---......... ........................_..................................................... _.. - -- - - --------• ............._.._._..------------------------- 'inal Inspection by: ---- ---------..................•-•--••--...._.. ..........................Date .........._... EH 13 2h1-b F3 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT 8 7]1 3M