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FOR OFFIC'e USI," F w �� APPLICATION FOR:SANITATION PERMIT ---------- _ Permit No. . ----------------------------------- {Complete in Triplicate] _ This Permit Expires 1 Year From Date Issued 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: t JOB ADDRESS/LOCATI [�7 =i---\(VE_ -[ 3 PaN -.___ .�---------------CENSUS TRACT __��_'_5_0--•-- Owner's Name ------ ` df+hl_------- 1,440_PM_;i�-------------------- '„ ----------------Phone ------------------------------ Address �Q �z- _ T 75-1_ City 71� �. $ FOP -------------------------------------- ------------------ ------------Contractor's Narne�._ 41-1-� I - -------------------- = Phone '_� License # ---- ------------ 1' F � f � F Installation will serve: Residence partment House f:,3 Commercial ❑Trailer Court i❑ ! IA Motel ❑Other --------------- -----------------------•--- Number of living units,.--,/------ Number of bedrooms �__Garbage Grinder ___ � Lot Size'- ., i - ----- ------- - Water Supply: Public System and name --------------- _________ Private 1' Character of soil to adepth of 3 feet; Sand❑ Silt,❑ Clay ❑ Peat❑ Sandy Loam Gay Loam ❑ Hardpan ❑ Adobe E` Fill (Plot plan, showing size of lot, location of system in relation-to-wells,buildings, .etc. must be placed on reverse side.) NEW INSTALLATION: (No septic`tank or seepage pit permi ed if-pub is available within 200 feet,] PACKAGE TREATMENT { ] SEPTIC TANK [ ] Si e _ i �] - -- ---------------------------------- Liquid Depth -----------------•-------- Capacity ____ ---------�111____T;Ype` ;'r------ ----- Material-- ------------- No. Compartments ---------------------- Distance -----...-- •-- --- Dstance .to neargtf; Well ------------ ----------------------Foundation --- - -----------f op. Line ---------- . ' LEACHING LINE [ ] :No- af I i'res _ _ __ ___ Lengt , of each line---------____ Total Length __ D' Box -•- Type Filter Materi I ____________________Dep t Filter; tVI ------------------- ----------_-_-_- ....... !// Distance to nearest` Well ------------ t_------ Foundati "`�___ _ �/-_ ro arty Line SEEPAGE PIT ( ] Depth ___-____-----!_- _) Diameter __..__ : ' 'Nu`mbe ` L� � I F ; oFilled Y s ❑ No ❑ Water Table Depth ______________ �� w R ! W ----------- ------- ck Sizer----4-"__<C-`------------- ! � ir / ( Distance to nearest'Well ---------- - ---!------- ---- ---------- undation -------- ------------ P Line ---------------------- } # T�------Dat. - ' --•-------1 REPSeAIR A aDk ION Pfev.Re au reme t- ------.•--- - --- ---- -_. Permit#� =-- _-- ---,_�:-------- 1 ---------- --------------------------- Disposal Field (Specify Requirements)fi__G0NW�T___/}T ____ }N_}�___ CS L S t t ; T---- --- X11( 779.- ------------------- -------- ----------- - W I_D -_ � — � � �R ! ^ ----- ons-AL T _ Q-s .----OF -�l-P__�_=�-U1�1•-IR �_nLE-�__- ---��irv�n!'T��_�d�-----�5=a=�,-_�_,_____��-�.��;_.J.�_ --- - -- - -- --------------------------- (Draw existih .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' CountyOrdinances, State Laws, and Rules cind�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 be a blect to Workman Compensation laws of California." Signed L��l � 'v -------•----�� -- --- - - -- --�- Owner ( ; B , Y - ------ -------------s Title - ----------- - (If other than owned � FOR .DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY t -= `---------------------------- BU DATE 'l�-- ' --- ---- - --- ILD1NG-PERMl7�1SSlJED -- -- - ---�- Q;4TE� `_-__-_-- ---• --�- -- - - ------ - - ADDITIONAL COMMENTS x }-�' 0 t-'-% �`� 1 A ._ 1 _ ----------•---- --------- ------ -- -- - -- ---------- - ------ ------ -------------------------------- Finai I tion by.- Dat - � ✓ - - - -- ------- ------ ----------------------------------- e __1:�+_- f�. -� SAN JOAQUIN LOCAL HEALTH D15TRICT y E. H. 9 1-'68 Rev. 5M