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FOR OFFICE USS; F APPLICATION FOR SANITATION PERMIT �/� -------------------------- p p Permit No. (Complete in Triplicate) Date I ---------------- -- ------------------------------------------------ This Permit Expires i Year From Date Issued lsued Application �s 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 wrth County Ordinance No. 549 and existing-Rules_and Qeg.ulations: � p JOB ADDRESS/LOCATION ---11.? '--- ----A4F --------------------R 1.P.at'�,t----- --CENSUS TRACT -----6-----.----.------ Owner's Name I-------&? _K_-7r+_1l4_0_RAIS---------- -------•--------------------------- --- --------Phone --------------------•--•--••-------- I ' Address { � ^-----F------ EL- -------------------------------- City ----- --------------------------------------•-----•------ Contractor's Name l4--c.D A116 -�7 (t 7_ _.__ f—5n---.License # --------- ------ Phone ----------------------------_ Installation will serve: Residence ❑Apartment House^E] Commercial QT railer Court''[] Motel ❑Other ------ Number of living units:-T=-- Number of bedrooms ___=__Garbage Grinder __7�7=_ Lot Size{__ _ rC _ EI E --------------- Water Supply: Public System and name ----------------- -- ------ ------------ ----- - -----------------------------------• --------Private Y t4i 1 C1. , Character of soillto a depth of 3 feet: Sand' S 'p Clay ❑ Peat E] Sandy Loam C7 Clay Loam_0x i Hardpan E] Adobe -E] Fill Material -- --------- If yes, type --------------------------- - ! l � - (Plot'plan, showing size of lot, location of system in relation to wells;buildings, etc: must be_,,placed on reverse side.) NEW t septic` seepage pit permitted if p blic�sewer is available within 200 feet,) PACKAGE REATM NT 5EP.TlC TANK, - iA �: � . Li uid De th --- — /T (No �[� Size,--5/ ►69 - I Capacity Compartments __-_.:•--•------------ z Distance to 'r,earest:Weil '`- ___�'___-__ _: ---.Foundation __'_ _____'f-______ Prop. Line ___>�____________ _ l 1 I ± i i C LEACHING LINE' [-r Na. of;Lines ____-------- Length of each line—_90 ---- - ---- Total Length �r l I 'p' Box��5_�,-•ype Filter Material Ro._Cf'e,Depth Filter Material '______/`------------------ res D!s ante to ne t: Well ____�Z7----------- Foundation-�---! -V ------ •Property Line .. ........... 1 SEEPAGE PIT`/,[ ] Depth _.____.__3____ _-_ Diameter _____--_---- Number ___________________________ Rock Filled Yes `❑ No C Water Table Depth -------------------- I ��.________Rock Size Disfiance to nearest4'Wdl ------------ -----.-Foundation -------------------- Prop. Line ----------------_-__-• REPAIR/ADDITION{Prev. Sanitation Permit-#---!---------"- -•------=---------------- Date --------------------------.-------) r i Septic Tank (Specify Requirementsl'scr__�_��'V--- L_.: i__��:�- -----` -----------------------------------------•---------------------------- 6 f:4 I _. .. ... Disposal f=ield ]Specify Requirements} _____________ _ ---------------- ' i _______ _________________ __ ` ' 1------ ----------- ---- ------ a -- -------------- ----r i----- -- - (Draw existing and required addition ,n reverse 4!de) y I hereby certjfy,that i have prepared,this application and That the work will-be done iri accord`anEe 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 manner as to become sub' t to Workman's dompensation Jaws of California." �'J I Signed -- d=am E Owner 4 1 i ----------------------- Title ------------ -- --------------------------------------- ---------------- i(If'other than owner) I ; FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- (-f'� .0 ----------------- ---- -------------------------------- -----------. DATE -----_37-- --- -�------------- BUILDING PERMIT ISSUED ------------------------------------------------------ - - --- ---DATE ----------- -•----- - - ADDI-TIONAL COMMENTS ------ ----------------------------------------------------------------- ----- y ------ -- ---- ---- - -- --------------------------------------------------------------- --------- ---------------------------------------- ------------------------ ------------- ---------------------------- ------------ Final Inspe =,---•--------------------------------------- - Date T _ ' SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M