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FOR OFFICE USE: „` ir- APPLICATION FOR SANITATION PERMIT ---- ---------------------=----------------- �o ' {Complete in Triplicate} Permit No.---------------------------------------------- 1r _._ This Permit Expires- -. Date Issued ----'----- -------------- ------------ - � � � 1 Year From bate Issued Application is hereby made to the San Joaquin Local Health for a q permit to construct-and- install the work herein described- This application is made in compliance with County Ordinance No.,549 and' existing Rules and Regulations: 1 JOB ADDRESS/LOCATION ----- -1--- _ ...... / o- - --------------------------------------- --CENSUS TRACT ----------------- Owner's --- --- - ---- Owner's Name - _ _eI2SCj Phone Q , 7 - ----- ---- `Z Address -- { = City _RR-l?-!�j� - -- n{ L Contractor's Naye --- �. `P '-----------=--------License # �( �Q phone Installation will serve: Residence ❑ Apartment House-0 Commercialrailer Court [( Motel ❑Other k Number of living units:------------ Number of bedrooms _________:_Garbage Grinder __._______- Lot Size_ _n e _- `�' Water,Supply: Public System and name�__________________-,-----------„ Private G Character of soll to a depth of 3 fest: Sand' Silt C P ❑ ❑ lay ❑ .Peat[] Sandy Loam 's - Clay,Loam:❑ Hardpan ❑ Adobe ❑`.` Fill Material ------------ If yes, type ___-_-____________________ (Plot plan, showing size of lot, location of system in relation to- wells, buildings, etc. must be placed on reverse side.) I NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] S•ize------------------------------------------------ Liquid Depth -------------------- acit Ca p YType Material---------------------- No. Compartments = Distance to nearest: Well ----------------- -- _____Foundation ---------------------- Prop. Line ----------- -_____. LEACHING LINE [ ] No. of Lines ---_-__________________ Length of each line--.- ------------- -------- Total Length 'D' Box -_ --------- Type Filter Material :______-____________Depth Filter Material __________________ Distance to nearest: Well ____--_______--_____-_- Foundation _ _- _____ Property Line SEEPAGE PIT Depth __ _2___-_- ___ eftmrefeT _/-/'__P_�1 �mberap-_____--____ /:__ "Rock Filled Yes �o i❑ Water Table Depth ___ __ ! = ----Rock Size _ Distance to nearest: Well ________ UU,_---- ------ ------Foundation -- --- Prop. Line REPAIR/ADDITION{Prev. Sonitotion Permit# ----------------------.---------------------- Date -------------- ) ------------- - Septic Tank {Specify.Requirements} ----------------------------------------------------- - Dis )osal Field {Specify Re uirements) --12 /�1 f2---- het-�/l-y --- QTR f�_r-d{/ J' e-C f C�WT44--,ti ---------------- --------------- --------------------- --------------------------------- ------------------------- papplication'—a'n'd - - = (Draw existing andrequire 'd_addition on reversee side) P 1 hereby certify that I have re ared this a lication aand 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. Nome owner or licen- sed agents signature certifies the following: s "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become suebiGt to W man's Compensation laws of California." Signed � -----------='------ Owner ---------------------- - ------------- BY �. �P ------------------ - ------------ Title (If o#her than ownsr) -------------------------------------------------------- . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED :BY -- -------- --------- ------ ----------- ------------. DATE __/-- - __!_.�--•--- ------------- BUILDING PERMIT ISSUED --------------------------DATE ------- ----- AL COMMENTS => --------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------- -- --------- --------- Ina Inspection by: -- - -- ------------------ - --.Date -- --.-�---j-- ----------.- ----- ---------=------------- - , -- --------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M..