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rOR OFFICE USE: w --- - ----... .�.r....�.y._..APPLICATION FOR,SANITATION,.PERMIT,... .,__ � . ,.,. , _ -7� _. (Complete in Triplicate) Permit No. ". ___:__ _. --------------- - ,r Date Issued _. __?�_.. _______________ This Permit Expires 1 Year From Date Issued 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: 71- , . .C '�y-�P .�r�E - -------JOB ADDRESS/LOCATION ._._ _._ CENSUS TRACT'_:__"__________ _________ Owner's Name / / " - --------------- ----------------------------- -------------------PhoneA0.7__4_&2/----•-•-- sAddress ------------------------------------------------Fly A00-9--. _` City �� --� / �----- -----------_--"----_-_=_- --•------ ' -�Contractors Name _77:2 (imA ------------------------------------------- ------ -----License ��O-____ PhonecP !3'14 Installation will serve: Residence ❑ Apartmen�t/House❑ Commercial:❑Trailer Court i❑ Motel ❑Other _[Z --------- Number of living units:....n --" Number of bedrooms .(7_______Garbage Grinder Lot Size ........... Water Supply: Public System and name ------------------------------------ Private [fir ' Character of soil to a depth of 3 feet: Sand'❑ Silt o Clay ❑ Peat❑ Sandy Loam -e Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ----- ------ If yes,type _________________�____-__ "T – _ - ------ `� f (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse Fside.) NEW INSTALLATION: (No septic tank or seep❑ a pit permitted f public is avail�le within 200 feet,J « PACKAGE TREATMENT { ] SEPTIC TANK![ Size _ _"� _4�, _X" q p - E •. « -:Ga�acaty� __ .Typ .._,' ---- Matericlk WW7 No. Compartments yL...._ _. If 1 Distance Pro"to"-nearest"Well __________ _ _________Foundation aP-._ - line Prop, A10--_1---------- 4:1 oe LEACHING LINE ; ; iNo. of Lines _ _____ Len g L _.�------- __--- Length of each line.-/4717. - Tota! Length _M-0_________________ a� Y45_" Type Filter Mat�ialACA________De Depth Filter Material ,Q____� K j'D' Box Yp - ---- p- ---------------- --�------------------ ------------- ----------- �--•------ ' Distance to nearest. Well Q1Foundation 7� Property LY'ne SEEPAGE PIT [ ] p � `- �� '� '� ..J�e th-•---_---------------- Diameter. __-- -Number .---------_.----_---------�Ra. ' Filled,.! Yes ❑ No i❑ a. • . Water Table Depth ------------------------ -------Rock Size ----= ---------------- 1A ��'i I Distance to nearest: Well ----------------------------------------Foundation ------------------ Drop. Line if . ==� ;-S-�----.-�--- --------_-- REPAfR/ADDITION{Prev. Sanitation Permit # ________. ________________ ______ --_ -- Date -------------'171__..__-___-__-____ Septic Tank (Specify Requirements) ------------------------------------------------------- -------------- ----------- �: 4 r ---------p------------------(Specify ---------------9------------ ------------------------ - ---------------------------- "_" w 4 i Dis osal Field 5 ecif Requirements) _ - ti �}1, --------------- Disposal - -----------•----.------- --------- --------------- -- . l I `----------------------- -- (Draw existing and required addition on reverse side[ , J i f hereby certify that I have prepared this application and that the work will be done in accoldance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Hoe owner or licen- sed agents signature certifies the following: „V °t }. ' "I certify that in the performance of the work for which this perrrttt rs l-§fWdd;–"'�hbll"not employ-any-person in such manner as to become subject to Workman's Compensation laws of CalifJrnia." I ' I i Signed --------------•----- 1 Owner [ G BY ` ------- + --------------•- Title _�G �C • rifiz (If of er than owner Ari 1 " FOR DEPARTMENT–USI:'-ONLY fr APPLICATION ACCEPTED BY _-- -----`---__F-- - - - ----------------------------------- -' DATE ---------------- BUILDING PERMIT ISSUED ------ ---------------------------- ---------------------------------------------------- DATE -------------- ---`.-;g------”t-------- -------------- ADDITIONAL COMMENTS _. -------------------------------------- ° = -` -- ----------- ----------------- - - i --------------------------------- ! f Final Inspection b Date -------------- -------- -----------r SAN JOAQUIN LOCAL HEALTH ..DISTRICT i .e_+'-..r.......,s...w ate: .w.«. .........u+-w+-....._. �++epw.+r.-+.•w - - E. H. 9 1-'68 Rev. 5M1