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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------ Permit No. .io (Complete in Triplicate) _ S� This Permit Expires 1 Year From Date Issued - Date Issued _?:7� -�� - 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. J ,g J013 ADDRESS/LOCATION c�Cl --------------- r /---- ��'g _ -----------r-�-1 J�T A_'-.__-.-CENSUS TRACT ------ I-•----- Owner's Name r --------�WZW71------------------------------------------- - --- � -- ------.Phone ----- --- p - ----5 _/-�_7_ Address 3 ff�,t --i---- r -------------------------------• City z??_d5r/�� —------------------------------------- Contractor's Name _;rzx 105�/ ---------------------------------------- ------.License es--- PhoneC ©. � Installation will serve: Residence M-KIPartment Nouse°❑ Commercial ❑Trailer Court Motel ❑Other ------ ------------------------------------- t Number of living units:___,/------- Number of bedrooms -/-------Garbage Grinder A/P---- Lot Size -�G� X��_---------- Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------_Private E�I Character of soil to a depth of 3 feet: Sancl'�It p Clay`0p-- Peat❑ Sandy Loam d Clay Loam ❑ ^ Hardpan ❑ Adobe❑ Fill Material -NQ--- If yes,.typ s (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse ;side.) NEW INSTALLATION: 140-iseptic!tank or seepage pit permitted if publicsewer is 9vailable within 200 feet,) 0 PACKAGE TREATMENT' I I SEPTIC TANK [ Size_(-rI9--- 4" ------------ Liquid Depth -7--- (� Capacity/•4047----- Typ ----7AFMateria ___-�� Na. Compartments �...... ......... d ( i Distance to nearest: Well __ �_______________________Foundation 149_- _____'-_ Prop. Line ______:':;.'..;...______ / aor LEACHING LINE [� No. of Lines .__/________________ Length of each line-__ Q_____-_...__.__ Total Length ___._______....._.-_ \'D' Box /YQ.-- Type Filter Material � lt------Depth Filter Material -4?---------------------------•--•----- 10, Distance to' nearest: Well - = ---------- Foundation J40----------------- Property Line :��----.:•--.__--- SEEPAGE PIT [ ] Depth ------------ ,-____,_Diameter, ............_--- Number ---------------------------- Rock�Flllej Yes ❑ No I] Water Table Depth �`"..�, .R(ock Size. ._:: -- - -- - Distance to nearest: Well -------------------------------•--' -'--Foundation _ ------- Prop. Line -----•• ----------- REPAIR/ADDITION(Prev. Sanitation Permit# --------- ------------------____-:-------------Date :-------------,---------------__--) SepticTank (Specify Requirements) --------------------------------------------------------------------------------- -----------------------------------------------------_-- DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- ---------- ----------------------------- --------------------------------------- - C11-R& L�-------w-------- --- `7�---------T-P--o (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 licen- sed agents signature certifies the following- "] 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 __ --_ __ Owner �- -- fid✓ By ---------------- '- - ----------------------------------- Title ------- (If o#herthan owner) FOR DEPARTMENT USE ONLY DATE g. 1 APPLICATION ACCEPTED BY _---ti-R-0_____________________________- A0� BUILDING PERMIT ISSUED ------ Th�- '�t�- ---DATE ------------------------------- ----------- ADDITIONAL COMMENTS . "CNS �k`a `---------------- ------------------------------ ------------=--------•-•---------------- ------=------ --------- - �_� _- � ----- --------------------- ---------------------------------------------------------------------------------------------- pwz -- -------- ----------------------------------------- ----- ---------------------------- - ------ --- -- ------------------------------------ - ---- Final Ins ction by: ,�� Date - SAN OA 11 OCAL HEALTH DISTRICT E. H. 9 t-'68 Rev. 5M r f