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cF FOR QFFICE I.JISE: ' - lJe r N'd° d1 � -,APFA ATION FOR SANITATION PERMIT q -- . ----- - :w. ` (Cmpleta:in Triplicate) Permit Nor ---- ----------- ----------------- This Permit Expires 1 Year From Date Issued Date Issued&.-, a_��O 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 existing Rules and Regulations: JOB ADDRESS/LOCATION -- ---------------,[ --•--- -- - ------CENSUS TRACT __ ............... Owner's Name -- Csr/ • Phone ' -0 -2 r --- Address -- -- ----- Z:Z�-- - -------------------•--. City _ cfSXjF ---------- Contractor's Name .... ...72_ �"------------- ---------------------------- ------.License # ---- ----:-------------- Phone------- - Installation will serve: Residence E-A-partment House[3 Commercial []Trailer Court f7 Motel ❑Other -------------- ------------------------------ Number ------------ ---------------Number of living units:------------ Number of bedrooms -----_Garbage Grinder ------___-- Lot Size __-��-.X__o�+� ---._..--. Water Supply: PublicSystem and name ----------- Private - - --------- El Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam .F] Clay Loam E - I 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.) V NEW INSTALLATION: (No se is tank or seepage pit permitted if public sewer is available within 200 feet,) � PACKAGE TREATMENT [ SEPTIC TANK[ ] Size... u__ ----,f —--------------- Liquid Dept#- -----1l�-__-------`�, a Capacity -&-e Type/_ 'e -6® ?_ Material-�'dl H_�k'� No. Compartments -------1W__ -%---- -q Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line --- -----------------� LEACHING LINE I i [ No. of Lines ------�_--_------- Length of each line------/----------- --- Total Length ---�,C-°----..-.---- _ /9 D' Box . - Type Filter Material "Pa t -------Depth Fitter Material -_--------------------------- i Distance to riearest: Wel! -__ --------- Foundation -._-_r --�_-______-- Property Line -----r9�_�------.-- SEEPAGE PIT [Lj' Z ' rer --------------_-- Rock Filled Yes No ;! Ai Water Table Depth Rock Size Z=ry y __V��- ' ---------- I Distance to nearest: Well --------/Q-0--------------------=Foundation ---- Prop. Line ...... ------ ----- Date ------- Septic Tank (Specify Requirements) .......9=/__ Disposal Field (Specify Requirements) --Z--------- -----P-•-...r ¢-Ze--- r , -�t ---- til _d �T`.'� ------ z --------- ------- ------------------------------------------------------------------------ i {Draw existing and required addition on r erse side) I hereby certify that .I have prepared this application and that the.work will be done in accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or liven- L, sed agents signature certifies the following: \ "I certify that iin erformance of the work for whitia 4-is permit is issued, 4 shall not ernplsy any person in such manner as to be,Con sect t s.Comp n Jaws of California.,, `. Signe - ---------------- Owner By --------------------- ----------------- --------------------------------------------------------------- Title (if other than owner) ----------- -------------------------- ------------ R DEPA RTtAENT USE ONLY APPLICATION ACCEPTED BY ------- ------------------- ----- DATE r BUILDING PERMIT ISSUED . DATE - ----- --- --- --9' ---- - --- -- - - ADDITI NAL COMME TS !/� i `Fm.r , R t _a�f _ _ :- -- -- r ,d - � _ f ,� j a G --1-r a �� - -- - ------ ---- --- --------- -- �--- ' = = ---- ys -- ------- Final Inspection by: ------------- Date ---- �-- _ .. ,pe�,�_,f�Q Jif S6 /� ' , �a QUIly LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.