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FOR OFFICE U51:: APPLICATION FOR SANITATION PERMIT v( / a.. Permit No.7_-Q'-_7__dbl ..................... )Complete in Triplicate) This Permit Expires t Year From Date Issued Date Issued .f.. _ _.. 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. 519 and existing Rules and Regulatioms: JOB ADDRESS/LOCA ION .. -- - - - ----••------------ -- 1 ..........CENSUS TRACT ----•-•-------•----------- Owner's Name ...J. .!11.R../ PAIZ E_l_l�f-r_...•...................................... i...... �7�Phorte ............. -•------•------------- -- ... Address ..._....._..M .. Ciry ----------------•---•-----•-----------•---•------... Contractor's Name GGS4 r3hO_%G,,o F� � �� --11 � �/Gj ----•--•-•-• .------- # 1�..-,...._�..1...- Phone ..q-7.....--••------3 Installation will serve: Residence Apartment Houseo Com"=al❑Trailer Court ❑ Motel ❑Other............................................. Number of living units------------- Number of bedrooms 3........Garbage Grinder ............ Lot Size ............................................ Water Supply: Public System and name _.................................._.------. .............._..........................................Private❑ Character of soil to a depth of 3 feet: Sand 0 Silt.❑ Gay ❑ Peat❑ Sandy Loam ❑. Clay Loam ❑ Hardpan❑ Adobe❑ Fill Material .......:....1f yes,type............... ............ J (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. Must be placed on reverse side.) Q NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 fe�ettt,) a PACKAGE TREATMENT [ ] SEPTIC TANK{ Sire.,� �0 "�. . Liquid DeptH QCT Capacity Type ..1 N...f Material. . � No. (Compartments �' _��.(/---- SPE•� ---------------------- Distance to nearest: Well /................. ...Foundation ....�Q.�_ Prop. Line s...?4...._.... Len th of..each Iin �" D LEACHING LINE [ j No. of Lines/....................... g / %` Total Length .......-.---•..-........._ 'D' Sox .L 'Type Filter Material `f�...�" _. e th Filte"r Material l� ....... Distance to nearest: Well ....... Foundation ....................... Property Line ........................ �i SEEPAGE PIT (] Depth .-.2 ...... Diameter .--... .... Number .....y................. Rock Filled Yes ❑ No Q c� r. Water Table Depth ...._..._...�Q...f_-- Rock Size ................................ r---------------- Distance to nearest: Well .•..1 ©. �.............Foundation ��... Prop. Line .s_� REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date .................................. ) y Septic Tank (Specify Requirements) DisposalField (Specify Requirements) --------•--•-------------------- ................................................................................................... .-----------•-------------------------------------------------•-•---- ✓"" !Draw existing and required addition on reverse side) I hereby certify that I 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:Dislrict. Horne owner or licen- sed agents signature certifies the following: "I certify that in th pe ormance of the work for which this permit is Issued, t &hail not employ any person in such manner as to become sub Work n's ampensation laws of California." Signed ------ j • . -- .......` ... --- _j- ------------ Owner By ---•--•-------------- Lai !�� ...------...... Title --........-----------•. ......... (if other than owner) _.._......_._ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . --- ...... •--•-----•..................••--•--•- -----. DATE �.�.. ..-.. _:......_.: BUILDINGPERMIT ISSUED ...-•--------------- -------------- --------- •••.... ..........--•- ----.:..--------------------------DATE : -------------------------------- ------_-- ADDITIONAL COMMENTS ..............:............ :..._.....__......._.. --• ..... .............. --•-------- ------------ ------------ -- --------..............._._.......................................... ...................... --- - - ------- ----- ---- Final Inspection by: .. ------------------------------------------------ e _. .-- . �. ........ ER 13 2h 1-68 Rev. SAN JOAQUtN LOCAL HEALTH DISTRICT 8�7h 3M