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FOROFFICEUSE: Ft_�p ll�s APPLICATION FOR SANITATION PERMIT --- �------------------------ ----------------- (Complete in Triplicate) Permit No: ------------------ - =- ------------------------------------------- ______________________.______________--------------- This Permit Expires 1 Year From Date Issued Date Issued _ _ S`C� 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 Ordina 9 nd existing Rules and Regulations: JOB ADDRESS/LOCATIONd�Z-f^��II- Q-�S- ----- ---, �--- ---- -/NMAW EN5 S 7R CT ------- -.-y.----------- Owner's Name -_ v- (C_ 1 ---------------- ••---------------------------------------------- -------------------Phone�� '4. 1.7 --- Address --�-0,3__2'] ............ ------7 W_4111Y--- -------__'City / -•/�1u1� ------------�---------�----------- Contractor's Name y� i _ /---� 1--e--------------------------- #:Z50. �d_____ Phone '+ Installation will serve: Residence Rf Apartment House❑ Commercial❑Trailer Court l❑ Motel ❑Other -------------------------------------------- g g ------- Number of living units:________.__ Number of bedroom Garba a Grinder p -_ Lot Size ___ --- Water Supply: Public System and name ------------------- -------------------------------------------------------------------------------------------Private . a �-- --Characterof-soilto-a'deptfi--of-3-feet.—Sand�K -Siltp�Clay--❑Peat-❑ —Sandy-L-oam-G- day-Loam-❑�-- - -� �- Hardpan ❑ Adobe ❑ Fill Material .4 .--- If yes, type ---------------------------- (Plot ___.____________________(Plot plan, showing size of lot, location of system in relation to wells, buildings, .etc. must be placed on reverse side:} O NEW INSTALLATION: (No septic tank or seepage pit permitted if pu lic Aewer i;ravaiia le within 200 feet,) � W PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size____ ____ ___ __- liquid Depth 01------------ Capacity �/.Z -�---- Type Nl=i A-5---- Materic�l_�U�Vd_ �No. Compartments -�---------..-•-- ______-Foundation ._..I_____�_ _____ Pro Line _____ _ - Distance to nearest: Well _._��________________ D _ p. �_.___._..._ LEACHING LINE [ ] No. of Lines ----4-------------- Length of each line________-___.______ Total Length ---�.-- --..--_-•_ ,s Distance t�� Type Filter Material �� ____Depth .Filter JNaterial ______��________________ _____________ V Box _ _ _ r _ � o nearest: Well __r..) �_________ Foundation A)-------------- Property Line ---( SEEPAGE PIT [ ] Depth ___ --------------- Diameter ________________ Number ---------------------------- Rock Filled Yes [] No Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line -------- ......... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) ---------------------------------------------------------------------------------------------------------------- --------------------------- DisposalField (Specify Requirements) ---------------------------------------- --------------------------------------------------------------------------------- ---------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) - I hereby certify that I have prepared this appl'icat'ion 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 mannerr as to beco ub' tt to rkman's Corp sation laws of California." l Signed r - V `f' ------------ -- Owner By ---------- --------------------------=---------------------------------- ---------------- Title -------------------- --------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- --------------------------------------------------------------------------. DATE ------�=Z ----------- BUILDINGPERMIT ISSUED --------------------------------- ------------------------------------------------------------------------DATE ------------------------------- ----------- ADDITIONAL COMMENTS ------------------------------------ --------- ----- --- - ------------------------------------ ---------- .......--------------------------- .� = --------------------------------------------------------------------------------------� " ------------------------------------ X�e ------------- --------------------------------- --------- --- - --- ------------------- '" ------------------------------- --- - -------------------------------------------------- Final ----------------------------------------------- s Final Inspection Yf`,' - ----------------------- ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 .,1-'68 Rev. 5M I