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FOR OFFICE'USE. APPLICATION FOR SANITATION PERMIT f Permit No. -=- ., ...... --------------------------------------------------------- (Complete in Triplicate) / ---------------------- Date Issued _ l--�- This Permit Expires 1 Year From Date Issued ----- , Application is hereby made to the Son 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: Y - - J 1 ' CENSUS TRACT c _`_ f � - T�� JOB ADDRESS/LOCATION .---,__►'-------- _ � Owner's Name ------------111I__TP----------- -----------------------------------------•---------- - ------Phone - -----------------------------•--- �7- -A[--------- �-------.-��_!------------------ City ---�'MA----------------------------------------- --------------- Contractor's Name _��R-y pl..-�1'v]_1�1_/V�-- -�`�-'------------------------License ---------_---------- ' ------------------------------ %a X, Ior Re ce [];Aportmerit House Commercial m❑Trailer Court ;❑ ill serve: Installation w Motel ❑ Other _'4.1------------ ----- Number of living units:___._ Number of bedrooms __�-----Garbage Grinder - o -- Lot Size _______ ________, --Private ______ _. Water Supply: Public System and-name ----------------------tiR--:---------------------------- - -------- -- s❑� Character of soil to a depth of-3 feet: Sand'❑ Silt Cl Clay E] Peat F1 Sandy Loam Clay Loam ❑ r Hardpan ❑ Adobe ❑ Fill Material_-- If yes, type -------------=---- (Plot plan, showing size 9of lot, Location of system in relation`to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: '(Nb septic tank or seepage pit permitted if public sewer is available within 200 feet,) �t -� PACKAGE TREATMENT SEPTIC TANKw.:{ ] Size, ----------------------- ---------- ----- Liquid Depthth ------------•----- tms Capacity Yp Material---------------------- No. Compar -------............ --- -• �' I Distance to nearest: Well ___ ____________________ Foundation ----------------- Prop. Line ---------------------- LEACHING LINE { ] ':No. of Lines -------------------- length of each line---_------------------ ------ Total Length ------- -------------------- '- D'e tti `Filter Material -------------------------------------------- '•i `D' Box ------- --- TYpe Filter Material----------�r---- - P .�___---------- Foundation ------------------------ Property Line. ------------ ---------- Distance to nearest: Well _ SEEPAGE PIT. [ ] Depth ----- --- Diameter "---------------- Number ------------------- _______ Rock Filled Yes ❑ No 9❑ --------- - - .. E__.� ..�— -e Water Table Depth Rock Size ----------------- t 25 Dista..rice tc'nearest: Well -------------------•---------------- Foundation -------------------- Prop. Line -----.----------•-- ._ �. --------- ----- Date -----------•-----•----------------1 , REPAIRJADDITION(Prev. Sanitation Permit#- ..---------_------------- ------------------------ - --------------'� -t-------!_V"_- ------- Dis osal Field [S ecify Requirements) ---J 11 r— TL dr---�-NF—------FfkO ------------------- . --•--------------- Se tic Tank (Specify Requirements) °� P p � � • e N -------------- t'S x -5----------5h�Pfd_ � pl y - ;:- _ -Y ---- - r i------------------- --- ---- ---- ---------- ---=-- (Draw existing and required addition on reverse side) I hereby certify that 11 have prepared:thisapplicationand-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: 1.1 certify that in the performance of the work for which this permit is issuecOl shall noi'_employ any person in such manner as to become subject to"Workn's Compensation la of California." r Owner �a,? Signed - --- -- � -- / ---- ------ �t By --=- -s,---- _ ---------,- ------------- -------------------------- F _ -6 (If other than owner) i FOR DEPARTMENT USE ONLY . x ACCEPTED BY _- -. R. �------ - i------------------------------ APPLICATIONyDATE -------- 7- BUILDING PERMIT ISSUED --__------------------------------------ Ate. -acs , ----------=---------=-------- ---- =DATE ------- --------- --------- ----------�-- ADDITIONALCOMMENTS -------- --------------------- ------------------- ------------------------------- ------ -- --- -- ------------------------------------------------------------------------------------------------ --------------------- ------------- --- --------- -------------- ---------- --------- y -�'t ----------------------------------------- r�.�------- -- Date Final Inspecti'ora.,bys`�- -- - - ----- ------------------ ---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M