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FOR OFFICE USE: ie a r APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No; 1 ---•-- -------------------------------------------- ---------------- ----------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued 7=yO 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: ' 1`(.e' TI _ _` CENSUS TRACT -_. N JOB ADDRESS/LOCATION .-----------�, ? .---f"---------- J Owner's Name ___ __ ._ d �-11 L 1_�'S------C75W_Is�Pi_�1_.C7"/L�/ + phone ZZ2�/.. Address - ��._ 1 _Ti _BW"P_.__. City -------------------------- �� . _. _ •---------.License# Phone Contractor's Name _._ l�""�-_ rt Installation will serve: Residence @'Xpartmen# House-f] Commercial ❑Trailer Court ❑ 1 Motel El Other.__ Number of living un,ts:a - _" um er o "0eei ooms i � - �="°�'Garba e-Grinder�r�_�:_ Water Supply: Public System and name ----I- '�� 0 ____" �'j" y! "" " --- Private ❑ Character of poil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam,<Clay loam ❑ ' Hard an Adobe❑ Fill Material V__ Ifes '! I tYpi ¢----------- (Plot..plan, sl owing size! of lot, location of systemY in relation -to wells, buildings, etc. mutt' be placed on reverse side.) \ NEW INSTALLATION: f(.No septic tank or seepage,pit permitted if public sewer isfavailable�i ithin 200)feet,) W PACKAGE TREATMENTi f ] SEPTiC TANK ,r/� �� r{ Size------Y�---1 1': _ Liquid Depth -------------- ,Capacity ---------------"_--- Type �Q�dj�Ej) Material_ QIVOR ao� lcor�part�ents ------._`��--�_� -------- --- i �J Distance to nearest; Well tcM._Vv--------- - -------Foundation .....49A Pro Line ___ II . LEACHING LINE [ . No. of Lines -- Length of each line f dotal s�s a Length fel. ;D' Box i j !r I 5 Type Filter Materia Qf`t___Depth Filter Material _ 1 �y: �y IDistance to nearest: Well x ;T d � ' l ANUh� ion __c_�V_ ¢Property Line ---------•--.-- SEEPACs�E,R.I [ ] Depth -- --------------- T, �-~f�iarneter ��, � -w _ � q -1 ,.� *• = r--_' Rock Filled Yes No �[] IRo ❑ �N Water Tabi ,Depth --------------------- ------._-T.ymaize ---------------� -- - • do tattce to'nearest..Weli '�_ --- i J •" `' E [ Prop? Line a • Foundation�z"*..,, } .---- REPAIR/ADD TION[Pre'v. Sanitation Permit#________________________ ____ ) - ---- ---- -- Date-------------•-----------•-�------- Septic Tank [Specify Requirements) - ��T �-- � �'- '.3 i .- 'j� t ----------------- Disposal - - - &iremrents)`..-----. w Y__. . _""-----------------------...4 �" , �, ------------------------ ----- ------------- ------- :[ ----------------------------------- --------------------------- (Draw " ----- ----- - �_. [Draw existing and ie. aired addition on.reverse-siclel t - 4��kq p 5�ti'ss s ,on .reverse hereby certify that l Nerve pr pared this application and that the'work-wvill be done in accordanci with San Joaquin County Ordinances, State Laws';; and Rules and Regul0.0 s of-tl.6"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 n t employ i as to become subject to Wor an's COM pe s 'on laws of California." Ir p Y an Y person in such manner Signed - i BYj title(If other than owner) i ----------- ------ ------- ----------------------- J -- ------- - =OR DEPARTMENT USE ONLY BU i APPLICATION ACCEPTED BY_._AL _V, c DATE " �- ILDII�TG.._PERIU['IT...ISSUED-_.�.,..n._------------------------------------ �__. � - __.�..�........`=::��.....�..-.� �- - --- ---�------�--------- ADDITIONAL COMMENTS . - E � ---- --- - --- - � ----------------------------- ._ _ '----------------------------------------------- ----- - -- ------- Final Inspection b -�P" � p Y Date _. _ ---•- SAN JOAQUIN LOCAL HEALTH DISTRICT H. E. 9 1-'68 Rev. 5M