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FOR OFFICE USE: APPLICATION FOR (SANITATION PERMIT --------------------------- (Complete in TRplicatel Permit No. ---------=----------------------------------------------- --------------------------------------------------------- This Permit Expires 1 Year.From Date Issued Date Issued _4100- 21 dl ? - Via^off 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/LOCATIONIC - -- --- ! --•----------------------- Owner's Name ----- a;Z11 fec4-----5 p'7.3------------Phone _ Address?-1ISFAIP-A4 7" --------- City ---- -- ----- --------------------------------------- ------- Contractor's Name . -- - - --- ----- --------License #/000/f---------- Phone Yb6--3*!y_...... Installation will serve: Residencev partment House❑ Commercial ❑Trailer Court ',❑ MotelF] Other -------------------------------------------- � F Number of living units.-_/------ Number of bedrooJms ---__Garbage Grinder ------------ Lot Size _____��__-------`Q______ Water Supply: Public System and name ________________ V --__--Private Character of soil to a depth of 3 feet: Sand'El Silt❑ Clay ❑ Peat❑ Sandy Loam H6ay-,1099, ❑ Hardpan ❑ Adobe❑ Fill Material .'�__.___-- If yes,type -------------!---__________ i (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.rmust be pled on reverse side.) NEW INSTALLATION: (No septic tank or,seepage pit permitted if public sewer is available within 200 feet,) } / r .. q, S/ #. PACKAGE TREATMENT X_y . _�SEPTIC TANK:[ ] 5ize___ _ 3. . _________ Li uid Depth _________________________ Capacity _ -+ � Type -------------------- Material&�-- No. Compartments -_--.-�_-_-_------- i i of Distance to nearest. Well -- -------- _____._..__/-___Foundation ----/_0 Prop. Line .....4�__ -------- LEACHING LINE [ ] No. of Lines -------V------------- Length of each Iine_____dt2Fd_------------ Total Length 4_? 'D' Box ---V___ Type Filter Material _______Depth Filter Material ------_______ ________________ Distance to nearest: Well --------5V__-_______ Foundation ---__l _____________ Property Line -----s___ __.__._.... SEEPAGE PITp -- -+- ----------- Diameter [ } De th ____---___-- - ___-- Number ----------------------------- Rock; Filled Yes ❑ No �❑ Wates,Table Depth -----------------------------------------I --------------------------- ----- '__,.,-.Rock Size ------ r-------------------- Distance4o nearest:,Well ..-------------------------------------- ----- ^f------_'`c Prop. Line -------------_-----•-- y` kV i REPAIR/ADDITION(Prev. Sanitation Permit# _-_ ___.____. - ) ------ ------- Date ---- �� ..Septic Tank (Specify Requirements) ----- -- e y --- r )1?4- r ...--.--- I 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 liven- sed agents signature certifies the following: '" cP _ '' _y w JA VC ' "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 --------- - -- --------- Ow, ner BY ---------a Title' '' ----------------------------------- (If other th wned r s •, FOR DEPART 1 USE ONLY APPLICATION ACCEPTED B -.- "=- -- ----- --------- -------- DATE _._ __/J�ZI----------- BUILDINGPERMIT ISSUED ----------------------------------------------------------------- ---`-----�---------------------DATE ------------------------------------------- ADDITIONAL COMMENTS ----------- ---------------------------------------------------------------------------------- ---- ---------------------------------------- ---vim-- r --------- - -- --=-------- Final Inspection by: -------------------- ----------------------------------------------------------------Date " l ? -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.,9 1-'613 Rev. 5M - yr