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FOR OFFICE USE: APPLICATION.FOR SANITATION PERMIT Permit(Complete in Triplicate) No. . i'. 7y�" •' Dote Issued .. �y " This Permit Expires T Year From Dab Issued "> ? Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein k , dasLribed. This application is made In compliance with County Ordinance No. 549 ani exit Ing Rules and Regulations 3y !O ' JOB ADDRESS/LOCATION ... .1.�_ 5... .I ✓Pe ...... ... .CE�NSUS TRACT ................... Owner's Name .........41p.)r.6le .....4r........N:Gt_ .................. ................ . ... ....phone..B..ST.R:.'7..2.0.z.a Address ...............��.�/. (.�ZyS.... V..iZ . )14!..e:..fX .....City .�rflfa�axi......................._..6._.......... _......_..� s "! �S Contractor's Name ...... .t./.�. d....O................... . ................. . .......license # ........................ Phone .........................._: '. ' Installation will serve, Residence M-4-crtment House Commercial ❑Traller Court ❑ � Motel❑Other..................................6......... `! Number of living units.....4..... Number of bedrooms ............Garbage Grinder ............ Lot Size . CPO- 10, Water Supply: Public System and name ........................................................._...................................................Private Character of coil to a depth of 3 feet. Sand o Silt❑ Clay 12--p-eat❑ Sandy Loam ❑ Clay loam❑ . f Hardpan❑ Adobe ❑ Fill Mcterial............ If Yes.type............................ (Plot plan, showing size of lot, location of system In relation to wells, buildings, etc, must be placed on reverse side.){�'� 1, NEW INSTALLATION, (No septic tank or seepage pit permitted If public sewer is available within 200 Feet,) , va '- PACKAGE TREA'MENT ( ] SEPTIC TANK; ] Slze................................................ Liquid Depth .......................... Capacity .................... Type .................... Material................... No. Compartments ' 's5 Distance to nearest, Well .....6..............................Foundation ...................... Prop. Line..........._......... iLEACHING LINE ( ] No. of Lines ........................ Length of each line............................ Total Length ............................ Jlel,.., 'D' Box ............ Type Filter Material ....................Depth Filter Material ..................................... Distance to nearest, Well ........................ Foundation _.........6.6.......... Property line ........................ SEEPAGE PIT [ j Depth ................ ... Diameter ............... Number ............................ Rock Felled Yes ❑ No Q WaterTable Depth ................................................Rock Size ................................ Distance to nearest. Well ........................................Foundation .................... Prop. Line ..................._. REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................I Septic Tank (Specify Requirements) ................ . . .......... Disposal Field [Specify Regyirements) .. .�c,t�-.e`.Z,,,.res.r .sS�� ....! -!zs .....G+..-x6 ,/.Q4,r., . �! ................................-...�....,..............................................................................................................................I......................... ...........__,.. ...._.. ............. ._.................................._..........................._............................................................................................ (Draw existing and required addition on reverse side) I hereby certify that 1 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 Son Joaquin Local Health District. flame owner or liceo- sod agents signature certifies the following: "I certify that in the performance of the work for which this permit Is Issued, 1 shelf not employ any person in such manner as to become sC�u'++b[e�te Workman's Compensation laws of California." Signed . 4....4......r•...U/..lig"'"..................I............................... Owner By .. . ......_....................ne"r'..................................................... Title ...............__................ ......._................. ......... Ili other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...........,</..^f.._.................. ................................................-- DATE .....l I;; ..... ,Y................. BUILDINGPERMIT ISSUED ..........................................................................................................DATE .......................................... ADDITIONAL COMMENTS ........................................................................... ................................. .................................................. ...........................................................................................-............................................................................................................. ........................................................................................................-.............................................................................................. . ......................... y;........................... ...... . . ............. Final Inspection by: .................... ... �...-::... �.�...............................................................Dab...�...'W"..�J.yY... .,............... SAN JOAQUIN LOCAL HEALTH DISTRICT ~ E. H.13 24 1.'68 Rey,SM 7172 3 M