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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - ----------------------- il (Complete in Triplicate) Permit No. _�_�-_5. __Z ------------------------------ This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the 51 Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in with County Ordinance No. 549 and existing Rules and Regulations: 11 �1g -1 /-� JOB ADDRESS/LOCATION _._ i /"r',—rvc-------1�_- 'I!1-- ----- � - ----------CENSUS TRACT -------------------------- _ A5/fir'{� _ r/ 1 Owner's Name I_ GI__ _ate - F l !' Phone Address _ .f C� % �� ` =7 . City Contractor's Name ------------- ��; `- �' s`_��l�l ` ----------------- � Pone .'- � r � ------.License --- �.- - hr5"` Installation will serve: Residence Apartment House�❑ Commercial ❑Trailer Court ;❑ i Motel ❑ Other -------------------------------------------- Number of living units: /---- Number of bedrooms ------------Garbage Grinder ------------ Lot Size � =f4<y __-_-_________ ---------------------------------------- --------------------------- -•------------Private Water Supply: Public System and name ___________.________._ __ [Sr .i Character of soil to a depth of 3 feet: Sand''NI Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam.0 �pHardpan ❑ - Adobe ❑ Fill Material ------------ If yes, type ____________________________ (Plot plan, showing size 1'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,) PACKAGE TREATMENT i] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth _--____________-.-...-_-- Material______________-___. _ No. Compartments ________________---._- C�apacitY -------------------- Type --------------------- - p � Distance to nearest: Well ----------------- ------------------Foundation ----.--- ----- ------ Prop. Line .-------------- ------ LEACHING LINE [ ] " No.�of Lines _____.______.________ Length of each line_______________________ ____ Total Length _________-____-.-.-..-.-__ 'D' Box ------------ Type Filter Mater' I --------------------Depth Filter Material -------------------- --•~-- istance to nearest: Well __________ _____________ Foundation _________ . Property Line -______________._-._- SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ______.__. -________________ Rock Filled Yes [] No i❑ Water Table Depth -------------- ---------------------------------Rock Si a -------------------------------- :i ; Distance to nearest: Well --- ------------------------------------Foun ation -------------------- Prop. Line ---------------------_ �i REPAIR/ADDITION(Prev. Sanitation Permit# _.____ _________________________-__.___-___ Date _-__-_____________________________} Septic Tank (Specify Requirements) ----------------------------------------------------------------- -------- ,i -- .�...r..- - e Disposal Field '{Specify Requirements) -------- - ---�_ _---- �-------- - f�------ 't------` ' -� � ----- r3 ---------- ------F770-�-?-------- �%�" -------- .— ---------------------------------------------------- ----------------------------------------- -- ------------------ ------------------------- -- ----------------------------------------------------------------------------------------- y (Draw existing and required addition on reverse side) I hereby certify that I halve 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: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Wgrkman's_Compensation laws of California." I Signed ----- II -------- ---------------- ----------- Owner ' .- w ' ° ' Title ---------------- ------------------------ ------------------------------- If other than owner) Iw FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED ii BY ------------------------------------------ DATE —---------- BUILDING PERMIT ISSUED --------------------------------------------- -------DATE -- ------------------------------------ ---------------------------------------------- --- ADDITIONALCOMMENTS ----------------------------------------------------------------------I---- ------------- -------- ---------------------------------------------------------- -------------------------------------- 'i ------- ------ ---- - - - -------- ------------------------------------------------------------------- ------------------------ ----------------- -- - - -- ------ ------- ---------------------------------------- 4----------------------------- `I ------ ----- -------- - Fina1 Ins e--c- b ------------ ---- ------------ -------------------------- �-------------- P Y --- Date �f SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M