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FSR OFFICE USE: t -' - -- APPLICATION FOR SANITATIONRMIT 7�.. `"r (Complete in Triplicate) Permit No. This Permit Expires 1 Year From Date Issued Date Issued _. `_1-- 7 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. 549 and a isting ,les and Regulations: (�� JO ADDRESS/LOCATION . __-- - -- - r.-- - -_ e, --- -; '-__-- ---- 1 -- - -------CENSUS TRACT /� _l 61,01-11P Owner's Name - �-- - - --------- ---- �----- -------•-----a•------------------ -- ----_-> ----- �--- - Phone ------------------------------------ i cit YG D7 Address ------------ -------------- ;1 License #/`r� _ Phonesa � Contractor's Name _______ ___,__ *" f Installation will serve: Residence ❑ Apartment House❑ Commercial Trailer Cburt ;[�] r470,0 �� Motel E]Other ----------------------- IL .,..�,�� s Number of living units:---`----- Number of bedrooms ____.Garbage�Grinders � , - Lot Size aA-10" Q---- ------ - l Water Supply: Public System and name __! -__ ---------- ,: �'--------------------------------Private Character of soil to a depth of 3 feet: Sand' Silt,w , CIO I Peat Sand `"Loam ❑ Clay Loam ❑ of p ❑ ❑ Y, ❑ Y' 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted 4f,pvblic sewer is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK.O Size q p Ca acit « TypeMaterial _ 7 __ No. Compartments __ FCf-r- 'e_ .._______ Distance to nearest: Well ___ � Foundation Prop. Line __ i LEACHING LINE No. of Lines -- ------------ - ---- Length of each l'invdp'-,_94�P---- Total Length / y / �_--__--_ _._ IN 'D' Box Type Filter Material � Depth Fi teMaterial --------•- -------------------- Q Distance to nearest: Well Foundation Property Line, �------ ------ SEEPAGE PITDe th ----_ Diameter _ ' _'_ �hlurnber _____________ _-___ Rock Filled Yes No ! wJ p Water Table Depth -------------- ------------------------= ------=Rock_Size-----:------------ --------------- Distance to nearest: Well _________________i1__ -__________________Foundation _.______._____=:____ Prop. Line _________-______.____. I .,�. :� �i , REPAIR/ADDITION(Prev. Sanitation Permit# ______________ ----------L_, Date.;_:,_'._._::_:___________________ ) Septic Tank (Specify Requirements) -------------------------=----------------------------------=-r=__-__-------------.----.-' =a-------, ------------------------- 0 V Disposal Field (Specify Requirements) �/---------- ----------------------------------- - ------------- ------------------- .- -� _r_._...� ( -- - ------------------------------------------------------ ------------------------------------ ------- -- (Draw existing and required addition on reverse side) p 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,,dr licen. 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 in such manner as to become subject to Workman'sCompensati laws of California," ,f Signed ----------------------?t� own�er) ------------------ --- -------------------------. Owner BY - '= G ------ --------------- Title ------� y ------------- - ---------------- --- , (If othevA FOR DEPARTMENT USE ONLY- APPLICATION NLY-APPLICATION ACCEPTED BY s------- --------- -------- --------- --- DA"i 0-�_a- -F-7-f------ BUILDING PERMIT ISSUED _.____ - =- - ----------------------------- -- --------"'- ----------------- "'Df�TE 1 ADDITIONAL COMMENTS -------------"/---='-- --------- ------------------------------- - ________________________________________ --------- ^�________ - --- ________ ______________________________________________________________ ____________________________________________________________ _ _____________ ________________ ____________________________________^ __.________________. Final Inspection by: _-- ---- " -- -��S----��-'--r --�„ _�._---- ------- ---------------Date _�--/o- ---- ----------------------- ~ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. SMG�-