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FOR�OffiCE USE: `. A.PPLICATION FOR SANITATION PERMIT Perm 7Sr�.,� ..........- 1 `p Triplicate) �1 L ................::............. teen lets in Tri 11 Date-Issued .:l.`.�:--7•-•- R This Permit Expires I Year from.Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install fhe work herein described. This application is mode.'In compliance with Coupty Ordinance No. 549 and existing Rules nd Regulations, .� r S c6m x fi d , Mira 'JOB ADDRESS/LOCATION'"�J �+ =r .�..y� :.aD. .:....:................. CENSUS TRACT ....._............ 'Owner's Name 6",,0.nj60 J.a)( :...... ......... —..... ...................Phone _.. ...................... c / Address ...... . . � T��- -•--------- ---------------------•--------•-•--- City -- -�-``77i�...,_._...........................................,---- Contractar's Name -- -- ----._License # c� 9 - �••• Phone�•, rd � Installation will serve: Residence❑Apartment House❑ Commercial Trailer Court Motel ❑Other ----------------------------- ------------- ; y Number of living units:------------ Number of bedrooms ------------Garbage Grinder ---------- Lot Size Q_,1.-(a �1� •f- Water Supply: Public System and name .........-•------------- .............--....'- ---------•--•-............................. -------..........:_Private Character of soil to a depth of 3 feet: . Sand'❑ Silt.❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam 0 Hardpan ❑ Adobe ❑ Fill Material ........... 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 sewer is available within 200 feet,} PACKAGE TREATMENT SEPTIC TANK f Size-R. yr *9-/r. ................... Liquid Depth .............. 91 p ty _ ------- Type�C,,�o• . Material- __ No.. Compartments .. -0----•-----00 Capacity Distance to nearest: Well ------ O- ---••-----.-....Foundation ._- U.______..... Prop.line ..f4...............N [ ] -----41..k.. .--•--- Len a filter Material ....�l'.y e LEACHING LINE Na• of lines Length of each line.___:_ �............. Total Length.,� D Box Type Filter Material .� __f ..Dep ............. ....:.......... Distancelo nearest: Well ....,S.70............. Foundation ....f_0..'........ Property Line ............ h SEEPAGE PIT Depth ----_------ ...... Diameter ................ Number :.... __ - ........ Rock Filled- Yes ❑ No 0 WaterTable Depth ........•........................................Rock Size __----------_ --------------- Distance to nearest: Well --------------------••--•--•-----------.Foundation Prop. Line .. ----•----- REPAIR/ADDITION(Prev. Sanitation Permit# ......................••--._.--------------- Date ...--------- .........----------.-) Septic Tank (Specify Requirements) ................................................:......I.....--•--•........... • .....----••--•--------_...._.....-- ' Disposal Field ISpecify Requirements) ------------------- ............-•-•..................__.._...;................... -•-••---------------- ------7C ------- ------------------------------••-.....__._......-•----------....--•-----------•---• ........-----••....-•-•-• ` ---------------------=-------------_-----------. .. _ ------.. ---•---------...._..----------......... { (Draw existing and required addition on reverse side)�- � ! l hereby certify that l have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances, State taws, and Rules and Regulations of the Son 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, 1 shall not employ any person In such manner as to become subject to Workman's Compensation laws of California." � Signed-,,,,--- .. ... ... ..... .. ..................... Owner Title _;.��er� •--------------•-- ......... R (If other the owner) DEyAjRTMFNT_r, E ONLY _....- - •• ----------------. DATE . .. .... APPLICATION ACCEPTED BY ------- -- --=- ------ - •• - ..... _. DATE _.... • ------------------------------- BUILDING PERMIT ISSUED ---------------- __`ADDITIONAL COMMENTS -------------------------------------------------- --------......•..... •----- •- ----------------- ----- ............. �- r. •: `: r -a-1- 5c •-- _ - cQw�.t. ....... . =---------------------------- - -----------------'------------- Date ! - .... final Ins•action by: .--- - - .............................•-••-- ------._.._. EH 13 24 1-68 v- � SAN. JOAQUIN LOCAL HEALTH DISTRICT 874 311