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FOR OFFICE US APPLICATION FOR SANITATION PERMIT .......................... . T� Permit No. 'V (Complete in Triplicate) _....:................ .......".-........_.__.._.._.._ This Permit Expires 1 Year From Date Issued 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: JOB ADDRESS/LOCATION .. '�� •.....•....-_. ........CENSUS TRACT t Owner's',Name ......................... .. _.Phone _.. , ... ,-•..r• y _ Address City C .?" . •--. Com/ Cdntrbctor's Name':._:- C :'1.....- :_,License#. 7. .;�3 Phon'e X ::�. � _ W }F Installation will serve: Residence;0-Apartment House Commercial OTrailer-Covrt a„ .14 Motel ❑.Other . ...:.:...... ....... Number s ' € of living units:___'.__. Number of-becdrooms ; . g der 4/P._;Lot Size'.. • �' J�Gayr-ba a Gnn Water Supply: Public System and name ...Cil / !/� !yr '- ��f" P- Private Character of soil to a depth of'3 feet: Sand n Silt I] "Clay [] Peat 0 Sandy Loam ❑ Clay,l`aam i - -- - Hardpan �] Adobe : Fill'.hAatenai _.. .. '__-- If yes, pe _.._ (Plot:plan,.showing. size of: lot,. location of system in:relation' to wells, buildings,.,etc. st be,piaced on.,reverse-_,side.)' NEW INSTALLATION: (No septic tank or,seepage pit.permitted if:public sewer is availabie within 200,feet, i PACKAGE TREATMENT/[ ] SEPTIC TANK f_] :Size________________________________ .........._'_ Liquid "Depth --.:-•:-_- y......- _ '`Ca acit p Y TYPe Material No. Compartments _J .Foundation Pro Line . 'Distance to nearest: Well ...............�'---------......:.. ------:_..,....__:__- p• ...:...... .---- � ___ Total length. _.._�.._ Length of each line. E LEACHING LINT= [.] No. of Lines .......:....... . �`` - g -••-=- •• 9 ' "D' Box ..... Type Filter Material`.........:......:...Depth' Filter Material ;........_.:._.--_.-•-_.............. fi Distance to nearest: Well ' ` '" Foundation ...... :..... ; Property Line ' SEEPAGE PIT [ ] Depth Rock Filled Yes No. Diameters. .... •--• Number ._._:.. - --- C] Q 1Na.terlTabk_Depth----------_---- ..............................Rock Size , -------- Distance tonearest: Well -- ------------------- ..............Foundation ._..................... Prop. Line :- ' REPAIR/ADDITION(Prev. Sanitation Permit+# ...........-•--••-•-----=------ ........ bate . ...................... . . .. S Septic Tank (Specify Requirements) -•......:........... ._...-••--•• -•-- ---......._° ..._... . . _ Disposal Field (Specify Requirements -- .. .. .. .. .�., ... (Draw'existing and required addition on reverse side). „ 1 thereby certify that I, have prepared this application and:that the work will ,be'dome in`accorddnce ;with San Joaquin County Ordinances, State Laws,' and Rules and�Regulations of the'San Jodquin Local Health District. home'*,Amer or licen- sed agents signature certifies the following:/ "I certify that in the performance of,the work fot Which this permit is Issued, i shall'not employ any 'person in such manner as to become subject to WorkmcinV CaMpensation laws of California." " Signed g Own i, f......_ ...... -_-Owner (if o r t an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED Y . - ................. _..._................................ DATE I s� BUILDING PERMIT ISSUED'... DATE _ __ _.................... . . s ADDITIONAL COMMENTS ._... --•••- . ...................•----- --•-••..........................._.................................... -- ............................... ---------------------------------•---- ,-..............__.T.--------'--- •--•- ........-- _ I i �194 Final Inspection by: .. _ ... to -- N JOA UIN LOCAL` HEALTH"DISTRICT F w 13 24 1_-.&A kev_ sm 7/72 3 M