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f FOR OFFICE USE. APPLICATION ICOR SANITATION PERMIT ' .................................... ----......._.....: t _ - dWe e� ICornpiete in,Triplicate) v. ..4_; _ Permit 7. P it No .......................:....................... .57 r -� ,i This Pennit Expires t Year From Date lssu Date Issued .7=- •7._ Application is hereby made to the San Joaquin Local Health District for a permit to nstruct and install the work herein described. this application is made in compliance with County Ordinance No. 549 grid xisting Rules and Regulations:11 s�yyyy�� '' (('' JOB ADDRESS/LOC TION ......il!*_l./Lrr...._... '_ F ¢,rJ..77�_..V.1._. .............CENSUS TRACT ........................... Owner's Name d.f+?....� !a1 ................... .... - ,...............:... :.. Phone).31.�._�if "i� Address ........... _!T" 1. ................. f ._...........City .. - ---------------- Contractor's Name . License 9lt Phone -••-•---------------------------•-.. ._.....I...--------.. .•---•• . ----•-•. ............... p Installation will serve: Residence' t partment House I-] Commercial OTrailer Court 0 Motel Other ........... Number of living units------ Number of bedrooms Garba a Grinder Lot$ize Water Supply: Public System and name ------ ................. Private Character of soil to a depth of 3 feet: Sand'[ Silt❑ Clay ❑ Peat Q Sandy Loam ❑ Clay Loam Q Hardpan❑ Adobe 0 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,} Liquid Depth PACKAGE TREATMENT I ) SEPTIC TANK` Size..... -- Capacity .--....- Type .�- -_-- Material. =�" � No KCompartments . AM71A1k//,6'i stance to nearest: Welt' .......::.Foundation - 4� `� ..... . Prop. Line _51.1 ....... NG E H No. of Lines __lpA� _-.--... Length of each Total Length ........... �� . 'D" Box .._ .... Type Filter Material . AYepth Filter Material .------ ....................:. I� C G�� tl e1y V*41 Distance to nearest: Well ...............:w...... Foundation ........................ Property line ....................... SEEPAGE PIT Depth --- .�...... Diameter �..--•?'-. Number ..... ....P............ Rock Filled Yes JR No Water Table Depth ................... ---- ------..........Rock Size ......••.................... Distance to nearest: Well ��: ..Foundation .................... Prop. Line ...... . REPAIR/ADDITION(Prev. Sanitation Permit# ..............................I............• Date ...,--.--.} Septic Tante (Specify Requirements) ............................................... ... .... ......... Disposal Field (Specify Requirements) --•--------------- .._-!.............-"'.-•----� -•-------...................-------- -------------- ---------- --------------------------------------- -- ................ ---------------------------- ------........ )Draw existing and required addi'tlon'on reverse side) '°' ` , ! 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`if #he'San Joaquin Local Health;District. Noma 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 shalt not employ any person in such manner as to became sub ec ,to.Workma 's C pensation laws of California. k ilk " '� " { Signed _._._ --- _ Owner 4 .� BY T •--------------------- ------------------._ � .. .__..._-. :.— (If otheran owner} FOR PARTMENT U E.ONLY. _ �f) APPLICATION ACCEPTED BY .�it'f ; - �.r� ` DATE .-... BUILDING PERMIT ISSUED _...... • -------------------------DATE ...._..._._......-------- ----......_.._... ADDITIONAL COMMENTS - .._..... .......................... ---------------------------------•---- -..___-_p__________________________ __ _ _______ _____ ____________- -- --------------- ----------------------- _--------- _---------------------------------------------------------------- _____ _._e____.� Final Ins ection by: ......�, .. ............ .... --------•-- -•-----------_._---•------------._..._..... gate ..-.(.-__. ..._ EH 13 2h 1-68 Rev, 5M SAN JOA IN LOCAL HEALTH DISTRICT 8/7h 3M