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' FOR 0000 USE: APPLICATION FOR SANITATION PERMIT Permit No. ...7- 7_Z ... (Complete In Triplicate) ' _.. :. :................................... ,, ..�,.•. Date Issued ....... This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the worts heroin described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations,, JOS ADDRESS/LOCATION ,! . P/ .../.lfz'r / �l ...rCV...............................CENSUS TRACT ........:...........:..... Owner's Name ..... ..--. _ ........................... . . ... ....................:........Phone .................................... Address •. • �I . .....................•.........................City .. T Q!��............. ...... .........:..... Contractor's Name �:, �.�64-• ....................License ... _. .. Phone ,�' .�` :-- -• , Installation will serve,, Residence❑Apartment House Commercial❑Traile►Court [3 i -Motel❑Other............................................ ` '........ Garbs a Grinder ........---- Lot Slee . ... Number of living,unitss../------- Number of bedrooms _. ......... g Water Supply: Public System and name......................................__....._..........._......................................-----........Privets❑ Character of soil to a depth of 3 feat: Sand 13E3 Silt 0 Clay ❑ Peat Sandy Loom Iff Clay Learn❑ Fill Material If yes type ❑ ............... ............ Adobe Hardpan❑� a � 4 f Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATIONe (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK Ij ] Size................................................ Liquid Depth .......................... Capacity .................... Type ,a .....Moterlat. ................... No. Compartments ......................p Distance to nearest: Well ...........:.. :.... .........Foundation ...................... Prop. Line .............. ' .... _LEACHING L114E ~[ ; No. of Lines ........................ Length of each line.:........................ Total Length ............................ �rT 'D' Sox ............ Type Filter Material .....................Depth Filter Material ......................... , ........... . f Distance to neoreif%jwell ...................... .{.Foundation ........................ Property line ................. ... SEEPAGE PIT [ Q Depth ................ Diameter .........- Number ............................ Rock Filled Yes 0 No ...... ............Rock Size ..............•................. Water Table Depth r i Distance to nearest: Well ............................. .........Foundation .................... Prop. Un* .................... REPAIR/ADDITION(Prov. Sanitation Permit# ............................................. Date ............................... . .y Septic Tank.(Spedfy Requirements) ........................................................................................................................_-................ t - Disoosol Field'(Specify Requirementsg= - ........_... ....................................... •.........--•• .---...... ..............---.......--••.......----•-.......... ............... � (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work r will be done in accordance with Sar Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin•Local Health District. Home Owner of 11COW sed agents signature certifies the following: ' °°I certify that in the performance of the work for which this permit is issued, I shall not employ any person M such manner as to become sub(ec o arkma 's Compensation laws of California." , n S fined .......... ..................... Owner eCJlJ By .............. 7ifie .................................................................... ..... # (If other than owner{ : FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY 1� ._ .............................._......... DATE . . .... _ . .. ,. � .. DATE . ................. .... BUILDING PERMIT ISSUED ..................... ADDITIONAL COMMENTS .......................................................... •....--••- - - --------------- .....................-......................................................................... ....---................ _........................ ...................'..................-" ........ - ............I......................... . ( - :'.--- -. .... . - ... ................... ...- .. ........... ......_. .. ............ ....... qcto 7........ .._. ..e. ii Final Ins.pctonby: Di ...... 13 2a 1-68 Rev. 5H SAN a AQUIN LOCAL HEALTH DISTRICT 8�7h 3M