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FOR OFFICE USE: r ,APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. Ad,�-Zff. i ----------------------------------------- --------------- �- ---------------------------------- This.Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to th�QSaniJ:oagdi-n-Locale,HealthaD--,istrictzfor,- a permit to.construcf:andT'install the work herein .described. This applicdtibn is made-in'c6nplian�with,County-Qrdinan e-No._549 and existing Rules and Regulations: yJOB ADDRESSfLOCATI N _��S3I--------------------------) � I � F�r___-_ �"'" ' _ -. .,_:�� ------------------------------------- -.CENSUS TRACT Owner's Name _d ----- Phone . Address --------- ----- . '`'� city --- ---C1'�Ld N1 ---------------------------------- ' I Contractor's Name [01VIN E;r� y -------------------------------------------------------- -------- ---- Phone fLicense # ------- ----------- Installation will serve; Residence E-A_p�artment House❑ Commercial :❑Trailer Court '.❑ ' Motel ❑ Other I Number of living units:--- Number of bedrooms -------Garbage Grinder. A Lot Size i: _! } ' Water Supply: Public System and name -------- Private 1 Character of soil to a depth of 3 feet: 1.11 ' S' Cla ❑ y ❑ Peat Sandy Loam .❑ Clay Loam 3 Har JL an Adobe /,C _ � - Filli114ateria`I l(( - If yes, type -- ---------------------- (Plot -_t ----------------- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, a c� must b3laced on reverse side,) p NEW INSTALLATION: (No septic tank seepage pit petted if public sewer is av 11 within 200 feet,) 1oU PACKAGE TREATMENT [ ] SEPTIC TAN [ Size' ----------------------------------r-� I. -I _ Liquid Depth --.- " ] . -•- CA Capacity ------------ - --- Type --!------------------ Material------------------ L No. Compartments -------•------ -- tN Distance to nea est: Well E -+ �- -w ------------------------------------Foundation '�' ------ Prop. Line --- ----- LEACHING LINE [ ] No. of Lines _.--- - ��_�==��,.•�-Length of each line__________________ � X4 Total Length __-_-_--.-- D' Box ____.-___-- ype Filter Material --------------------Depth Filte Material 11 Distance to near st: Well -.._------------------- Foundation ------------ ! - ---------- _ =Property( Line F; PIT ❑ SEEPAGE [ ] Depth ______________ Diameter Number _.-. Rock Fillrd Yes No ppp Water Table Rock Size ' P - ------------------- . -- ! I �U�Q� Distance to nea a t: Wel!° -------------- Foundatio =:-- ---------r--- Prop. Line -----------•---•-- REPAIR/ADDITION.(Prev. Sanitation Per t-# __---------__-_.- - --- ------------------ } Septic Tank (Specify Requirements) --------------1 1'L-f�CG ____ - d--t--T 11 _ + ate ------- ----------•-•--- - !:-- Disposal, Q- Field ](Specify. Requirements) ��t�fc _ ---------ounCHt-l_bj --------<ZwNU T—!_. 6------- -77--7-- xn and re wired addition ------------------------------------------ -(Draw e ---- -------------- --- --_- - f 1 on on reverse side) I hereby certify that I have prepared this applicationF and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations ii "the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: i "I certify t i the perform c�of the work r which his p=e mit is�issued, I shall not employ any person in such manneras to b biect to Wor aCompen tion Ia of California." Sign d . •------- ..ff c . --------- Owner ----- -- ---- -- By --- --- ------------ ----- -------f St �' f Title ------ ------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY __--.__- ..__t_R-0-___I_ DATE x Bl11LDlNG-PERM•17 ISSUED -------------------- -------DATE---_--�.-----•_- ------------------------- ---------------COMMENTS >-, ------^Y---- �~ - - y ,r - --------- - 3 2 `s --------- - - - ------------- ------- ------------------------- --------- --- ----- ------------------------ -- - Final Ins --------------------------------- ate ___ -- � ` SAN JOAQUIN LOCAL HEALTH DISTRICT E. ., H. 9 4-1- 8�Rev-.'SM,