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r FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ...................... ......... ... - No.(G7.- $.... .. ., Permit_. .•......... (Complete in Triplicate) a ... ..l :. ..�)... .all• Date Issued.....-._ 1 ........................ ........`•. .. This Permit Expires 1 Year From 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 is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: a ��Qi ....................._... JOB ADDRESS/LOC I N ......�� ...� - �.-.. . � , r ....-'••. •...................CENSUS TRACT Owner's Name .�pT /�l� . ` ..- C�� Phan _... ...... Address ........ ♦ ..�.. i. �� . ............ ...................Gry -_... � .mss 1" .•-.... . Contractor's Name ......../ /C/._.... ..J....... .................................License# Installation will serve: Residence[]Apartment Houseo Commercial.[Frc Ter Court fl ` Motel []Other.... . i ................. Number of living units:....... Number of bedrooms .. ... _Garbage Grinder .... Lot Size .�1 k's 1.CD•-�•��C•rQ•G-� Water Supply: Public System and name ........................... Private(� Character of soil to a depth of 3 feet: Sand 0 Silt 0, Clay ❑ Peat[] Sandy Loam❑ Clay Loam❑ Hardpan[D Adobe [ Fill Material ............If yes,type............................ x (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse aide.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet) i` I „•_: �.f `'ze.•----- .... Liquid C3pth ......PACKAGE TREATMENT SEPTIC TANK ••-•••.•.-Capacity .{..LG. Type P/.v .�Nateriaa -c,-,a-&No. Compartments V(,1 't _v a Distance to nearest: Well .......,�...:_..............Foundation . a..�....... Prop. Line...a ........... LEACHING LINE [ No. of Lines .....ro._... .... Length of each ......... Total Length s; 'D' Box/.0.. Type Filter lviaterial ...��i......Depth Filter Material .......... ......... IV Distantnearest: Well _.....5�-l....... Foundation ./ ..�......... Property Line ..,w5................. SEEPAGE PIT [ Depth ....I;L� . Diameter ..... Number .....1.................. Rock Filled Yes &- :va Water Table Depth ....... 05... ........................Rock Size ....,�.L2....- Distance to nearest: Well ....�4 D9 .....................Foundation ..,� .-�...._ Prop. Line .. ./....... REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. SepticTank (Specify Requirements) ....-............................................................................._...._......_....---...._............._.._.............. Disposal Field iSpecify Requirements) ...............................•-----... ............................................................................................ ...................................I..................... ................. ...._.....-----...•..._.......•-.................................... r _...... .................................................................................... ()raw 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 Pegulations of the San Joaquin Local Health District. Home owner or licetr 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 to Workman's Compensation laws of California." Signed _ ......_- -- ---------------- -- . Owner er Title ..... GU.�7l-L/................. (If other than cwner FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .................................................. DATE... n...� "• �' BUILDING PERMIT ISSUED .................... DATE..........._.. ............................ ADDITIONALCOMMENTS .............................................................................................................................................................. ......................................................................... ................................................................ . .............................................................................................I................ ....................................... ................................................... ..... ... ............................................ ........................ .... Final Inspection by... P .. ..mss C-�!...... Date 4 SAN JOAQUIN LOCAL HEALTH DISTRICT i , E P. 9 1-'ba Rev. 5M