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FOR.OF "E USE: APPLICATION FOR SANITATION PERMIT --------------------- \.. (Complete in Triplicate) - '6_-------- - q p - ------------_------_--- This Permit Expires 1 Year From Date Date Issued 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: JOB ADDRESS/LOCATION /- ----- `3 - - - -C�--! l--- - °------ ------ -----CENSUS TRACT ...._------------------. Owner's Name /C 1 _ ------- �� .. . / 7..0 - - Q Phone Address --- ---- - ---- - ?-L ------- ............City -----MM---------------------- - - ------------------................ Contractor's Name -------- -------- ----------- -- -- -------------- --------- -License # - - Phone Installation will serve: Residence Apartment House❑ Commercial❑Trailer Court C] le fj' y- � Motel ❑Other .-- ✓' ---------- -------- ------ ---------- ? -T ' Number of living units:---/._---- Number of bedroom ___.Garbage Grinder -- --------- Lot Size ..__.._.'----------------- .......... Water Supply: Public System and name ------------------------------------=---------------------------------•--------------•-------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe�ll 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 if public sewer is available within 200 feet,) G PACKAGE TREATMENT [ I SEPTIC TANK[ I Size.... -------.....-....-------------__.__.--- Liquid Depth ....._.----- _.__----- Capacity ----_....---------- Type ------------------ Material. No. Compartments ---------------....... Distance to nearest: Well ....................................Foundation ----------.---__------ Prop. Line .......... ---------- O� LEACHING LINE [ ] No. of Lines ------------------------ Length of each line------_------------_-------- Total Length ..------------ -_------_.. 'D' Box _..-------- Type Filter Material --------------------Depth Filter Material __-_ Distance to nearest: Well ---------- ._---------- Foundation ---_---------------..... Property Line ._........._._...__... SEEPAGE PIT [ ] Depth ------ ---- Diameter --- ------------ Number ----.__._.-------------_. Rock Filled Yes ❑ No ❑ WaterTable Depth -------- - ----- ------------------------------Rock Size -- ......------......_......_. Distance to nearest:Well ........................................Foundation ............... Prop. Line .------___------_.-._. REPAIR/ADDITION(Prev. Sanitation Permit# -------- -----------........................ Date .. ..-----) Septic Tank (Specify Requirements) ...------------------------------------------------------------_-----------...........-- --------------- ------ ................. Diss osaall Field (Specify Requirements) l--- -----�iCI� -. Cel.,1.I'1lYry---/L'�.�.C __l/C�P�----- -----QlL. _sI'f/6.,J'.lst/ otal�.--{dlilli------------ .a �.Y�.1�jj;1¢p-A6-,�dc - - (Dr existing and Tdquired ad 6 ion on rederyEside) I hereby codify 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 or 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 Las to become sub" t to Wgrkm �' Compensat•on laws of California." Signed ._.fruul ._ ---m------------*Owner By ---------------. -- -------------------------------------- litle -- L . - ---- (If other than owner) FOR DEPARTMENT USE ONLY LAPPLICATION ACCEPTED BY ---------- '- --------- -- ------------------ --------------------------• DATE _...�T'� :.�i BUILDING PERMIT I U D _-- _ __----- --------- ----------------- DATE -------____ ADDITIONAL CO S (j _--------- ...... ----------------------- - -- - = -- ------ -------------- ---- - �`-... � .' ' _._ _ . r - - ---------- --------------------- - ' .:::::.:::::: :::..:::_::::.:.:::::::::::::.. :::: _:_-------- ------ - tt FinalInspection by: Gr .c---------------- - ............ ----------------------------------------------------------.Date --- --7:4 LSAN JOAG2UIN LOCAL HEALiH DISTRICT E. H. 9 1-'68 Rev. 5M C r3r