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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 170-(,A4- Permit No_ --------------------- ----- -------------------- ------------------------------ (Complete in Triplicate) -------------------------- - Date Issued ! 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: JOB ADDRESS/LOCATION 1).?o IV----4-r CENSUS TRACT __7"r 0 Owner's Name --------iJ >-hY---------cE�__!/__�--�---------- -------"--------- Phone ✓ City - ey-------------------------------------------- -------------------Address ---------------- ------- �.- ----- �r 5 h. a:s . - �` _ Phoned -'7 -fir /-' Name f-= ,, f F _ :--------License # - ----------- Contractor's Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ',❑ 9 Motel ❑Other -------------------------------------------- I/. g ' Lot Size ' ---- ---- Number of living units:---_ _- -- Number of bedrooms -___Garbo e Grinder ---4 _____ _- --------------------------------------Private f Water Supply: Y S---•------------ - - Character of so!tola depth of 3f feet:name ilt❑ Clay ❑ Peat❑ Sandy Loam.❑ ClayLoam.E] Hardpan ❑ Adobe-F-1 Fill Material - 2_- if yes, type ---------------------------- {Plot 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 lsewer is available within 200 feet,] PACKAGE TREATMENT .{ ]�� SEPTIC TANK f] Size-----------------`-•------ ----:----------- -- - Liquid Depth -------------------------- N _ Ca acit - Material------------- ------ No.' Compartments ------•---------•=---- pY -- ----------- Type. ---------- ---- Distance to nearest; Well -------------- ______Foundation -----------I -------- Prop. Line ___-____-_------------ ---------------- LEACHING LINE [ ] No. of Lines --------- -----=------- Length of each line----------------------- T tal Length f _____De Depth Filter Mater l ___---___-- D' Box -------"-"-- TY a Filter Material ----------- -7------------ 'D' p Distance to nearest: Well ------------------------ Foundation ---------------------_--- Property Line ------------------- SEEPAGE ___-____.-_------. SEE_PAGE PIT Depth --------- ----- Diameter ---------------- Number Rock Filled Yes ❑ No .0 f Water Table Dep Rock Size --------------- ----------•---- ------------------------- • Distance to neares • e!I ______.__-__--__________ ----Foundation ..-- --- Prop. Line -----_-------- { REPAIR/ADDITION(Prev. Sanitation Permit ---------------------- Date ___--____-_-_----___--- 1 Septic Tank (Specify Requirements) ---------------Jpo ------- s" ------- -------- -------•--- - ------- --------,--------------------------. -� , ` DisposalrField (Specify Requirements) f -- - - !� �' . `�� ------To-----._:S-Cxlle---- ------ '� -------fl` --- 'y ------- - =------- uA� --- ------------ i (Draw existing and required addition on reverse side) r• I hereby certify that'1 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 licen- 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 1 as to become subject to Workman's Compensation laws of California." Signed ' Owner / ------------- - Title - ------ --- -.----- {If ofh�r ` R .DEPARTMENT USE ONLY '/ ------------ APPLICATION ACCEPTED .3Y --------- -- 11` '----------------------- ----------- ----------------------------------- DATE --- -- -- PERMIT ISSUED ---------- - ---- - --- ----------------------------------- DATE --------------------------------------- BUILDING - ADDITIONAL COMMENTS.__ ----------------- --------------------- - ----- ---- ------------------------------------------------------------------------- - - - - -- -- ------ ------------ ------------------------------------------ f --------I---- ------------------------ - Date ------ Final ----- ------lnsp i; SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M.