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i FOR OFFICE USE: Aj)ftICATION FOR SANITATION PERMIT --------- ---------------------------- ._ ,: (Complete in Triplicate) Permit No. ---------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued _!R-_Y.-21Q 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 __./F2kP- - - ri�ST� /L✓- - SIT. ----- �l-S--------------------CENSUS TRACT /- $------------ j Owner's Name Aze Y 9!� ( �1 Phone lam _ 3-7,6- Address w- ff } Address I-�--d-)------- i t ------------tt-a-------------------------- City _ r ---------------------------- ----• - Contractor's Name ____________________ __-____.-__--_-----License # ------------------------- Phone _____.___________._______._ Installation will serve: Residence ❑ Apartment House-F] Commercial :❑Trailer Court ',❑ Motel [TOther __G-_ -1C- C.--- ----------- ppe�rr ! Number of living units:_ Number of bedrooms ------------Garbage Grinder ----------- Lot Size ---- .7~ ---9-5 Water Supply: Public System and name __________ ____-___PrivateX Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam 91 Hardpang 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 permittedif pubj4 is available within 200 feet,) 00-PACKAGE TREATMENT [ ] SEPTIC TANKA 21 Size-- - .___ Liquid Depth ____- Capacit 6----,-- Type Compartments ----2-------------- Distance to nearest: Well _-76)_------------Foundation --- __�_______ Prop. Line _--�i ----- -- ------ LEACHING LINE [ ] No. of Lines ... _------------------- Length of each line--_.30__.j'_ %-0,1 Length ----3_.C?_______..-,I I — /�d D' Box _________._ Type Filter Material,f• _,�__ Dept alter Material ___ -----/Q_____ ,; ._ 4 'Distance to nearest: Well --s-01-------- Foundation _- /_0�------- Property Line __. ........... SEEPAGE PIT { ] Depth Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No Water-Table Depth ----------------------------------- ------------Rock Size ------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------r__..-..._,..__ REPAIR/ADDITION(Prev. Sanitation Permit# ___________________________________ 1 --------- Date --------------------------------- ) { Septic Tank (Specify Requirements) ----------------------------------------------------------------------------- ----------- -------------------- ------- Disposal Field {Specify Requirements) -------------- ' ------------------------------------------------------------= � 5 - ----------------------------------------------------------- I --------------------------------------------------------------------------------------------------------- ------------------------ ------------------------------------------------------------------- (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 taws, 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' as to beco bject to man' C pen �tion of California."Si ned -- Z 9 = Owner 1 I By -------- --------------------------- --------------------------------------------. Title -------- ------------ ---------- -------------------------------------- (If other than owner) FOR DEPARTMENT PSE ONLY APPLICATION ACCEPTED 8Y ---- -- ------ DATE — - -------- ..... '...... BUILDING PERMIT ISSUED ----------------------------------------- --DATE ------------------------------------ ------ --- -------------- ADDITIONAL COMMENTS -- ------------------------------------------------------------------------------ ------------------------------------= ---- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------- ----------Nf-A -" a Date� ^. Final Inspection by: -- - ---- -- ------------ ---- ---------------------- -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M