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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - Permit No: --- 7`�-5� 'r {Complete in Triplicate) w, --------------- This Permit'Expires 1---Year From Date Issued te Issued M Da _./-�Sl_�S Application is hereby made to the San Joaquin Local Hedlth District, for a per-mit to construct and install the work herein ` described. This application is made in compliance with County Ordinance N64'54.9,'.and existing Rules and Regulations: R ' -JOB ADDRESS/LOCATIO/N� .'-,-- Q_2- - - --- , ----- --------- - --- ---- ------_--CENSUS"TRACT .---- - ��- - .Owner's Name -- r --Ph ------------------------------------ ----- one ----- -----•--••-------- Address " Q Y .. City ------------------------ Ilan 1�` • ---=----•----------------License # ---- ----.'- ==---------- Phone ------------•---------- Contras Name ._ 1 Gln on will serve.. Residence Fet"A-partment�House-❑.Commercial;❑Trailer Court I❑ Motel ❑Other Number of livin units:--- - 0-1 { g � --._: tuber of bedrooms _:_Garbttage Grindier _______.___ L}o}t Size :._ _______________________________ Water Supply Public System andi name -- ---------- -_ [ ;-- 1_ ------ - -Z,R "-- _ 1------------------------------Private ❑ Characte'r.of;so h-to a delth of 3 feet. -Sand:' Silt • -.Ciay Peat .Sandy Loom ❑ Clay,Loom ❑ J P ❑ ❑ I Hardpan ❑ AdobeifllVlaterial _-_--- If yes, type ------------------------ It ________ _____"-"-- vl , : (Plot plan, showing(size of lot, location of system jn relation,,„,,to wells, buildings, etc. must be placed on reverse side.) 4 NEW INSTALLATION: (No septic tank or seep xre.pit permitted t' pu ii is i q a within 200 feet,) PACKAGE TREATMENT SEPTIC TANK' Size___ [ h - --- -------- ,i Depth 1! Capacity If (�J-- I ° Type ___ Materiel ____ No. Compartments. ___ o� ------------- istance to neare t' Well _____ -__, ---__________Foundation ___a! - ------- Prop.Prop. Line _� `1� •... - LEACWING,LINE No. of Lines ''' ,Length of each line-__- Q _ Total Length .___....___ 0 'D' Box . Q'5__ :Type Filter MatgnaJ -ti,Depth ,.Eilter-MWerial<;---------16 -:_-_.________•___ ______ Distance to nearest; Well ___-A-----"► _ Foundation; .__.�_ _______---------- Property Line. -l_ .__.__-._.__ SEEPAGE PIT Depth- ------------- -'` Diameter m._-- =-- Number _ - -----____--------- Rock Filled Yes �] No ❑ _ UVater Table •Depth ;-------------------- Ro�Size -------------------------------- Distance to nearest.. Well ----------------=-------------- ndation -.------------ ---- Prop. Line _.._..___= REPAIR/ADDITION Prev. Sanitation Perm# ____________________________________ _____ bate { :---------------------------------) Fy 3 Septic Tank (Specify Requirements) ---------- --------------- 1------ --------- -------- _- -------------------- Disposal Field [Specify Requirements) --- -- - - ------------------------------ -C� [Draw existing and required addition on reverse side) ' 1 .hereby certify that I have`.pre aced 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 signaturk certifies the following: f "I certiFy.th tin th4 per7Wk;ma 's the w rk for which this permit is issued, 1 shall not employ any person in such manner , as to bec a subj t to osat4on laws of California." igne . -- -----`---- ---. Owner-----------------------BY -------- ----------------- ---- --- ----------------- _7- t _- Title -- -------------------------- ------- F ----- ' == [If other than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY F -` ----- - ----------- ------ - -------- ------- • DATE ----- --4�S~- BUILDI:NG_PERMIT.:,�.ISSUED DATE________________ _ _________ ADDITIONAL COMMENTS - _ w F: - ..- -.M=:;.:_4. - ` ---------------------------------------------------------- - --- ----------- ------ __ -------------------- ____ _ _________________________________________ ___ .Final Inspe - Date '" ---- .f---_ --- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M