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FOR OFFICE USS,.' . R 11 _ ----------------------- APPLICATION FOR SANITATION PERMIT 4 � �k ------ ------ ------ I�----------------------------------- ------------ ,.I. !Conip�n Triplicate) Permit No: _�- !M . . ' . .. ------ * ------------------- -------- This Permit Expires 1 Year-From Date Issued Date Issued - Pplication is hereby.made to the San Joaquin Local Health District for a permit to construct ddescribed. This application is made in compliance with County Ordinance No'. 549 and ex stingnRulestalndt t Regulaonsrein Name ESS/LOCATION r -71.7_ Owners N --------- ---------------- ----CENSUS TRACT ------f_-_---_,--._ .r � B ADDR. --�� - � i ------- _ _ ------ ------ - Address! - -- - - - - - - -----•--. Ci `-yam,--- -----� _ ---Phone Contractor's Name L �M y 3.i' � I r - -- r ense # _._cT Phon f of. . Installation ,will serve: Residence (Apartment house❑ Commerciale❑Trailer Court ❑ l ! II i' Motel ❑ Otherw ------ :---.-.--- - f Number;of livin� ..units:..-_ !M ) 9 �____.__Number_of. bedrooms --y------ Grinder _.__"_______ Lot Size'.4k —-: Water Supply: Public S stemnd name __ S___--__-_- � PP Y� y �, r- ------...w.-- ---------------------------------- ------------------------------------- ---------Private � ' Character o Irsoil!to a depth of 3 feet: Sand'[ Silt❑ Clay ❑ Peat❑ ' ' Sandy Loam .� Clay Loam:❑ t Hardpan ❑ Adobe ❑ Fill Material ____ --------- ,- (Plot Ian, s it----- if yes, tYPe - ----'- ------------------ (Plot - --- ' I i e p howing size of lot, location of system in relation to wells, buildings, etc. must: be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT_ LI SEPTIC.TANK!["] g � = - Liquid Depth Capacity Type -7fi -_ Material__ I� ' - ` No. Compartments �., O I J li --------- Distance to nearest; Well -----_� r or- i .r ---------------Foundation ----Ab----- ---- Prop. Line _- f LEACHING LINE [ ] No. of Lines --�----------------- length of each line-___-- -' � r - =Total Length _! --- D' Box _ te,-_ Type Filter Material -__- _ •-"-_-- �p Cp/ Depth. Filter Materia,Proper '---; `" �C Distance to nearest: Well _--___,1 __Y_----- Foundation 1"(�-- _�, tyl r t ` � 6 SEEPAGE PIT 11 [ ) Depth --__- Diameter P Number - -----�------`------------ -Rock Filled Yes ❑ cNo ' h - Water Table Depth ------------------------------- Rock Sizef � ------ p Distance to nearest: Well ------------------------ x __FoundEation t"'' ------ Prop. Line = .......... Tank ION{Prev. Sanitation Permit# ______-_____"------___ - ` "' - [ REPAIR/ADDITION +�-•�p r Date _ 41'_. = -==------------ Septic Dis osal Field i�(Specify Requirements) -------------- €� 4 {Specify R Requirements) _ _________ -- ----- - ----------------------- 1 y {Drawexisting and required addition on revere side) i. 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 San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: iI r i "I certify that in the performance of the work for which this permit is issued, I shall not employ any prison in such manner as to become subject to Workman's Compensation laws of California.' Signed _- --------- �. I --------- ---- Owner (if other than owner) Title -- -------- f {= i „r FOR DEPARTMENT USE ONLY > , tit APPLICATION ACCEPTED BY_--_ BUILDING PERMIT ISSUED - _,- - � �` --- DATE ---� `� -- --------------------- __ �, - -------------- ------ ADDITIONAL COMMENTS __--� ,b -__ ---- --- D amu" — —� -,� - ----------- -- ------- ---- ri /��r�"�y�------ ----------------- ill�> ---------------------------`------------------------ �.. --1A�------------ ---f ------ Final Inspection Eby- -------------- -- � ip` - ------- --- - --------- !i - - - --------Date _.. -_..'_._ i SAN JOAQUIN LOCAL HEALTH' DISTRICT E. H. 9 1-'68 Rev. 5M 3