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r r 1 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------- ------------------0------------------- Permit No: U__ =- � --------- -------- ------------------- (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 i�n1 compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION _____A0sTI_-----------D---______--____________CENSUS TRACT -__-S_`S�__._.._. Owner's Name --------RVD,X_----_Q_omi-N-6-Q----------- ---------Phone ------------------------------------ Address ---------------L LTH_q ---- --------RD ----- ----. City ----- --------------------------------------- l�Cz1.�-�- --- ------ Contractor's Name __ License# ys�----cF' Phone ______________________________ Installation will serve: Residence X`X'partment House❑ Commercial ❑Trailer Court C1 Motel ❑Other-- -------------------------------------- -- -------------------- ------ A / Number of living units:__I------- Number of bedrooms __3_....Garbage Grinder _ D_ Lot Size ____/_ l��?-�__.T3 _..'''_-__- Water Supply: Public System and name ------------------------------- --------------------------------------------------------------------------------------------------------•-----------------------Private 2-1 Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat,❑�t Sandy Loam 5j�-' Clay Loam ;❑ Hardpan ❑ Adobe❑ Fill 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'sceptic tank or seepage it permitted,if public sewer is ava' a le within 200 feet,) v g . ,, PACKAGE TREATMENT. _[ 1> . SEPTIC TANK. _ Size __'_________.__ � ] ----:-:--------------------- '-- Liquid ,Depth _------ --------•-------- Capacity ------------- Type ------------------ Material------- ---- o.. Compartments ---------------- ---- Distance to nearest: Well ------------------,---------------Foundation ____ __;_________ Prop. Line ...................... LEACHING LINE [ ] No. of Lines ----------------------- Length of each line-------------------------- _ Total Length ._________-___.__--__--__•- D' Box ------------ Type Filter Material __'________________Depth Filter M trial Distance to nearest: Well _ ______-__________ Foundation ------------------ ----- 'Property Line __________________-__ - SEEPAGE PIT [ ] Depth _ _____ Diam er _________________ Number ---------------------- ___ Rock Filled Yes ❑ No 0 Water Table Depth ----------- ------------------------------------Rock Size -------- -------------- Distance to nearest: Well __ _______________________________Foundation ____ -------------- Prop. Line ...................... � I REPAIR/ADDITION(Prev. Sanitation Permit# -.-- -•._ _____ _____ Date ---------------___ ______________) Septic Tank (Specify Requirements) --=----------------------------------- ------------------ ------------------„--------------- ------ Disposal Field (Specify Requirements) ---._15T9_1L„_---_---1�_----X___-/sS_____X_____VF----9FF�'-----F/�rN--------- ------------13-F-D-------6T -----E ALD-----O �,,��-�T/�1f� : �E-AC1-1------kw_e_ ---=-----------------------=----------- ---------- ----------------------- --------------------- ----------- --------_--------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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, 1 shall not employ any person in such manner as to become subject to Work n's Compensation laws of California.” Signed ---------- - - ---- --- ----- --- ---------------------- Owner -- BY ------ -- -�----------=-�-------------------------- --------------- ------------------------ Title -------------------------------------------------- --------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- _L----- --5 JF-t\_(_----------------------------------------------------------------- DATE ------- = =7 = BUILQING PERMIT ISSUED - - ----- ---=-•- -------- ---- - ---------------------------------------------------------DATE ADDITIONALCOMMENTS - ------- -------------- --------------- -- •-------- ---- ------- -------- -------- ----- ----- - -------- r - - - ---------------------- ----- --- - -- ---- 71 Final Inspection by: ___________________ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M