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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------------------ Permit No. _ r.�ls? (Complete in Triplicate) " This Permit Expires T Year From Date Issued Date issuedA__oZ r 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: 4! r, ` [ -r I 16 JOB ADDRE55/LOCATION . ' ms s �-IN10_�� bi-�.--�.�x CEN5l3S TRACT Owner's Name - :------ 1� _ ------------- ice'-----------_- -------------------Phone ST -3/ 1--�----- i �: _ 4, Address ------------ e' `�__3 Q . •w y - Contractor's Name .. - ------------------License'# --------- ------ Phone - ~_(0/6.., Installation will serve: Residence partment House❑ Commercial ❑Trailer Court i0 ❑ ,r' _. Number of bedrooms __ Motel Other _ Number of living units:___ g ! � __`____ ____ �___.__Gdrbd e Grinder ��__ Lot Size ________ ________ _ Water Supply: Public System and nameJ- --- ------------------------------------------------- ------------------------------------Private ®� ' Character of soil to a depth of 3 feet: Sand ' ' Si:lt`❑ Gay .❑ Peat El Sandy Loam -E] Clay Loa� [jl Hardpan ❑0' Adobe'❑j Fill Material -W If yes,type - 142------, t 7 (Plot plan, showing size of lot, iocdtion� of system in relation to wells, buildings, .etc, must be placed on reverse side.) NEW INSTALLATION: (No septic Sank orseepagepit permitted if public sewer is avpilable within 200 feet,) PACKAGE TREATMENT &jJ SEPT1'C TANK' Size--- � _/J._ __� .__. ___ Liquid Depth -_ Capacity Y.,�__O__A?__ Type 1� ABMaterial_.�Qf No. Compartments V ' Di 3tance,,to`nearest: Well ------------ ------- ______,___IV____ Prop. Line ----- LEACHING ___LEACHING LINE No. of Lines 1 Len th of each line.-.. faLength ------- 'D' Box�/x�_5Tj ype�Filter Material ----Deptl��er Material --- - -,-------1---- - Distance : to nearest: Well -------- -------f\A--Fo,undation� -------2.4,0---------: Property Line _--�_________________ [ ] __.Rock ❑ 0SEEPAGE PET �Dep�th ____+_._______�____ Diameter ____.__:�__=s_�N�umber.��=�_5��____.-__.___-- Filled Yes No Water Table Depth ------------------------------------------------Rock Size ----------------`--------------- Distance to nearest: Well ---------------"-------"-"___--__--"-_..Foundation --------------------- Prop. Line __._____..________..__ REPAIR/ADDITION(Prev. Sanitation Permit Y# _._____ --------------------:-_---- .- -- Date__--_-.------------------- -----I SepticTank (Specify Requireffients) ------------------------------------------------------------------------------------------ , ------------ --------------------------- i Disposal Field (Specify eq-u irem{ tints) --------------------------- ------------------------ --;---•---------------------------------------- -------------------------------------------- --------------- — - - -------- ------------- ------------ ------------- -: f - --- i r' ------------------------------------ ------------------------------------------- -------- ------------------- ------------------------ C• � �'.I r--=- -' ---------------------------------- 1 (Draw existing and required addifion on reverse side) 1 hereby certify that I havi prepared this application anal nth at the work will be done in accordance with San Joaquin County Ordinances, State laws, and iRules and Regulations'f the San-Joaquin Local Health District.'Home owner or licen- sed agents signature certifies the following: tt„ "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 become s t t Workm n Compensation laws of California. . �s Signed 9 - ----- ------ ner gY7----------- -------------- --------------=--------- Title - -------------- -- ----------_-----------------;-`--------------------- (If other thanowner) # FOR"DEPARTMENT USE ONLY --- _ `` APPLICATION ACCEPTEDBY _-- R { --� . �- ------ ------ ----_ -------- DATE �Q_`� .'__k ._____-__-- BUILDING"PERMIT"ISSUED!- ----- -'`' - ------------------------ - - _. DATE ADDITIONAL COMMENTS -l�tr� � !Y "r "`------------�-------------------------------- ----- --------•-- ------ _�_� - -- ------- -------------------------------- -------------------------------- --- ------ -- ---- - - 1 � � Final-Inspection _. =__ = = ---------------= Date ---=f SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68-Rev. 5M'