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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT y ---------- ------------------------- (Complete in Triplicate) Permit No. This Permit Expires 1 Year From Date Issued Date Issued ---- ______7 --------------------------------------------------------- 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 17I_2_0C---I-S----A4 F �_---fel- ------CENSUS TRACT --•-- '�-�-?---- Owner's Name ------PR_u—----------R-EI-C-M J TTH------------ - ------------------------------------Phone ------- ----------- Address ----------1015---------P19-RK------- ---------------------yrs ; City --- ------------------------------------------ Contractor's Name _.X_7A11V- ----------------------- --------------------------------License # ------------------------ Phone -------------- __-:___-__-__ Installation will serve: Residence partment House❑ Commercial ❑Trailer Court l❑ Motel ❑ Other -----,--_ Number of living units:----/----- Number of bedrooms _____Garbage Grinde -45:5_ Lot Size __cXC4RE: -�. - ----------------------------------------------------------------------------- -- - ---- ---_- Privat � � Water Supply: Public System and name ------------------------ _ e:_ Character of soil to a depth of€3fei�t:_ + Sdtrd.- j Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam { Hardp&n dobe ❑f Fill Material _412?___ If yes, type ---------------------------- +f (Plot plan, showing size of lot, location of system in relati 8n to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION.:,,).f {hip septtc-ttmk or_seep a pit per'rr tted if public sewer is available within 200 feet,) � PACKAGE TREATMENT { ] SEPTI ANK -.�` Size _______________ Liquid Depth ---- -T __ .___...-- Capacity/ye-0____ Ty pe?,RMaterial- �No Compartments J i�tancef to- nearest: Well _, ___ """I'^ Foundation __ _- ----- Prop. Line _ .___ ..� LEACHING LINE C Nb of'tiines�-----------___ Length o'f each line___ Total Length _____1� _._.__ ---- --- ---- _._. . D .B ----- - Ir -- ---- ox __��_ Type Filter Material _ _��_Depth Filter-�PNlatenai __- -I�__ _ ____':___._____. Distance to nearest: Well ___�___�`-� Foundation,'"� _��_'�-__- PropertyLine ....... SEEPAGE PIT [of Depth � _�:__� _ Diameter�#,,-,X__ ._ Number ,__ ,_--__�__- __ Rock illed Yes k�--No C] Water Table Depth ------ —_ x-- Rock Size -1_-a- Distance to nearest: Well ------Ary Foundation -----._ Prop. Line -----•--'--�-•----•-- REPAIR/ADDITION(Prev. Sanitation Permit# _______,_______________________________ Date --------------__----_-..__-.-�-Y__) Septic Tank (Specify Requirements) ____________________ - Y ; Disposal Field (Specify Requirements) -------------------------------------------------------------- ---------------------------------------------------•- -- - ---- --- ------------------------------ ------------------------------------------------------------------ ------- -----------------------------------------_---- ------ ' a r � (Draw existing and required,addition on re- everse r se 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 Iicen- sed agents signature certifies the following: "1 certif t i the performance of he work for which this permit is issued, I shall not employ any person in such manner as to be a Iec to W mans ompens 1 laws of California. rf ' ----- Signe pp Owner By -------- -------------------- --------------- --------------------- ---_7 � #' Title ------------------------------------------------------------------------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------'7-n. - t------------- ___------_. DATE _--ate '_1115 PERMIT. ISSUED --------------------------- ----- ---- ----,.DATE..: ..- : .w_.- :- ------- ADDITIONAL -- -- ADDITIONALCOMMENTS -- ---- -- ------------------------------------------------------------------------------------------------------------------- --------------------------- ' ------------- ---------------------- --------- ------------------- - -------- --------------------------------------------------------------- ------- --- ------- 6 ----------------- - --- - Final Inspection ---'---- ---- --------------------------Date ---- - ` SAN JOAQUIN LOCAL HEALTH DISTRICT �y k E. H. 9 1-'68 Rev. 5M