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FOR OFFICE= L1SE: APPLICATION FOR SANITATION PERMIT Permit No. tr"Y--_e k (Complete in Triplicate) - -- --------------------------- •T Da'te issued t 1� This Permit Expires 1 Ye(a'r From Date Issued ? i ----------------------- --------------- ----------------- 37 � z- 2'q — s � , Application sreby made to the San Joaquin Local Health Dist fora permit to construct and install itha work herein i described. This application is made .in compliance with County Ordinance No.,549 and existing Rules ana Regulations: t3 ' SC-__CENSUS TRACT.--- ------------------ i JOB ,DRESS/LOCATIO ---- - ------_ }LL_ - Al---- R-I- ------- -- t 1"- f0 , Cit Phone Owner's Name Q. QR�1_�-i'---------------- ?� +� I Address _- �� 1-O _ �._ --- Y� � _ N '= l__' i = Contractor's Name ----- f F—�------------------------------------- --.License # ------ Phone --------------------------- Installation will serve: Residence partment Hous e1Commerciai:❑Trailer Court Motel ❑Other ---------------rte ` AY i __ Number of bedrooms___,_ -3--- Grinder _��__ Lot Size Number of living units:._ `Z 2 Q Water Supply: Public System and name ------------- --.- i -----_--------------------------------- ------Private ; i Character;of soil to a depth of feet: Sand Silt❑ Gay Peat Sandy Loam E] m E]T Cla' Loa Hardpan E] Adobe ❑ FilkMaterial _� Q___ 1f yes, type (Plot plan , showing size of lot, location of system in relation to wells, buildings, etc. must be place on reverse side.) I I > .1 1 1 W r' ` NEW INSTALLATION: (No septic tank or seepage .it permitted, �jf public,sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK:[e.]� Size--- ------------ Liquid Depthj__ tt Capacity -t_[2-Q_.0-__ Type -00-NC------- No. Compartments ----------------------iy y _ - 'stance to nearest: Well __ ________________-I _____Foundation __._. _____Id-.-- Prop. Line ____...-___________.._ LEACHING LINE [ N _ No. of Lines r-- Length ofeach I••ine--------------- __ --- Total Length ,� •7�----___ F i 'D' Box .4,-1'__ Type Filter Material _ _ Depth Filter Material ------ ,i____________________ __ � Distance to nearest: Well ---.-------5-Q---- Foundation -------------- ___ Property,, Line_ _________________----. - SEEPAGE,PIT Depth ____ ______________ Diameter ---------------i Number ------. ------------- ------ Rock Filled -Yes ❑ No i❑ Water Table Depth -- ----------------- ---=--- -=----_ Roek Size ------------------------------ Distance to nearest: Well -----------------i----------------------Fou dation -------------------- Prop. Lie --------------------_ REPAIR/ADDITION(Prev. Sanitation' Permit ____--__-.___-._______-_-___rJ Dafie�________________________________} ----------------- Septic dank {Specify Requirements_ --7-4 `�--,,.,�,� --�----- ----------�-- ------------------�- -'---------- --•---•--- ------ � Disposal Field (Specify Requirements) -------,�________-_-------- ---------------------------- rx------------------------------ ------- -------- -------------------------- ---- -------------- ---*__{Draw existing and req }ed-ddton on erre side { , t i r I hereby lertify-that I-have prepared this applic6Von and lhatZthe work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulationsiof the Van Jaaqu'n Local Health District. Home owner-or licen- sed agents signature certifies the following: l r i "I certify That in the performance of the work for which this)permit is issued, shall not employ any person in such manner as to be subject to Workman's Compensation laws of California." ' Signed ---------- �' -------- Owner B y Title --------------------- ; (If other than owner) ' FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- l - ------------------------`~-w- ------------------------------------- DATE _.__5.7/ � BE11Li71NG PER'NM1'IT"ISSUED ---- - -- - DATE_._' -_ .__-....�_. ADDITIONAL COMMENTS 8 C '` � = - i -T+ - --------------------------- ----------- - _.---- - = - r __�zg '---- l ----- --- ----------d� ' ----------------------------------- ------ -------------------- ------ ---- ---------- i ---- ------ ------------------- --- - -- - - Final InsP Date I SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M s<