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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT7 Permit No. .:7�---- (Complete in Triplicate) _ Dote issued -------------------- ---------____ This Permit Expires T Year From 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 in compliance with County Ordinance No. 5`49 and existing Rules and Regulations: JOB ADDRESS/LOCATION .-___ .d- cc290__- __---- __ H12 S1 � � IIc�DJ-------------CENSUS TRACT --- -5 --------- -- _ Owner's Name -------Rkv --------- ----- Z -----=-------------------------------------------=----------------- -------------------Phone �_3 SS--=------ Address ------------------ -�3----'Et --- j-0------ -------------------- ------------- - City -------- - ----------------------- ---------------------- •----------- Contractor's Name --------------------- 0_CLM_4e —----------------------------------------- # ------- ----------------- Phone ------------------•----------- Installation will serve: Residence F1Apartment House-E] Commercial :❑Trailer Court i0 r Motel ❑Other ----------7----------------------------------- - ------------------------- k i Number of living units:-------/__- Number of bedrooms ----t?-----Garbage Grinder ..- Lot Size ------- _ Water Supply: Public System and name ---------------------------------------- -------- ---------------------------------------- ,- Pr ivate " Character of soils a depifi of 3 Teet: Sand ❑ Silt 0 —_0 a'y Ef Peat❑ Sand oam� Clay Loam ❑ Hardpan ❑ Adobe'Fill Material ------------ If yes,type ---------------------------- (Plot plan, showing size of lot, location of system in relation to welds, buildings, etc, must be placed on reverse side.) NEW INSTALLATION: (No septicttank or seepage pit permitted if public sewer is available within 200 feet,) i PACKAGE TREATMENT [ ] SEPTIC TANK:[<� Size------------------------------------------------ Liquid Depth -------------------------- I Capacity -------- Type Cl?A---- Material ---_ No. Compartments _____c ........:.... r . Distance ao nearest: Well -----��Q-----------•---_--_--_.Foundation ------UP----------- Prop. Line ----SC!___:--.-__-- D [ ] No. of Lines -_ ------/_------- Length of each line------. --- x Total Length -- ----��© r P1 Lrr I--- 'D' Box {4_e_5---- Type Filter Material 2Q__i"0 _.---Depth Filter Material ---------t- ---------------------------•- f 13E9 Distance to nearest: Well ---00------------- Foundation ____ . Property Line, ___P___--___-_---- SEEPAGE PIT [ ] Depth -- --------------- Diameter ----------__--__ Number ---------------------------- Rock Filled Yes ❑ No ► Water Table Depth -' - _______Rock Size -------------------------------- Distance -____-___------------------ -Distance to nearest: Well ----------------- ---=-='---------------Foundation -------------------- Prop. Line -----------------.---- i -} REPAIR/ADDITION(Prev. Sanitation Permit# •-----------------�---=------------- - Date ---------------------------------- i. -------------------------------- Septic Tank (Specify Requirements) `�r L_ ------------------- ------- 1 L Disposal Field (Specify Requirements} ..,----------- -'------------------------------------------------------ --------------------- ---------------•---- --------- --F _ _ --------i---- ------------- -------------- --- - .. rte.. �. (Draw existing and required addition on reverse side) I hereby certify that I 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 sof the work for which this permit is issued, I shall not employ any person in such manner ` as to become ubject to Workma 's Com nsati.on laws of California." Signed ..................................... ---------------- ------------------ Owner 9 BY --------------- -------- ------------------------ Title ---------_--------- ------------- tT ---------------------------------------------------- - (If other than owner) r i FOR DEPA1tTME USE NLY r I --- -------- ---------- - ---------- - -----. DATE _._- .. �7 7- APPLICATION ACCEPTED BY __.____ BUILDING PERMIT ISSUED ---- ----=`-- ----------- DATE .. ------------- --------- - ADDITIONAL COMMENTS --------- -- ------------------- ------ - --------- -------------•----------------- --- ------------------------------ ------------------------------------------- c ---------------------------------------------------------- ------------------------- ----------------------------------- -------- ---------------------- --- ------- - --- -- ------------------------ -------------------------------------- ---- = ----- ---- -- - -- - -- - Final Inspetfi+on bY ------- ---------------- Data ' -- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M -r