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FOR OFFICE USE: ---- ------------------ --------------------- ---- APPLICATION FOR SANITATION PERMIT Permit No: {Complete in Tripliratel ------------------------------------------- - Da,te Issued -7-x-37 0 ________________________.___-___--___--------------- This Permit Expires 1 Year From Date Issued l 1 Application is hereby made to the San Joaquin Local Health District for a permit to construct] Land install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules' and Regulations: JOB ADDRESS/LOCATI �__rr/17DO�.3- rV -----R-)-Por4-- f -�_' CENSUS TRACT —----------------------- 1 Name �HIV_------5�_j ---------------------------------------------- -------------�----Phone _ --------------------------------- c r Address . 197o io --sem :�.P� --------RD- ------------ City -- p�w Phan-----------------------•- -•----- Contractor's Name ----Q_U4✓N-�_ ---------------- -- - License # } I e -------------------- ......... will serve: Residence ❑Apartment House-E] Commercial :❑Traller$l�� Motel ❑Other A--------------------------- ---------- nk 1 Nurnbe pf_lir in units. -.... Number of bedrooms --)2---Garbage Grinder,4: - _---J4 B ------ ----------------------- - -------------------9 •. 1 -:-�xx�- -- ----� �'' s--- ---Private Water Supply�blic System and name - __-.- ---r----------- - $^ Character of soil to asdepth of 3 feet: Sand ❑ Silt_❑. Clay❑„W Peat❑- Syandy Loa d, Cla Loam E] iHardan.[ {-1 gciab '[] FitlMateri '=wV: If yes;type 7� - {Plot plan, showing size of lot, location of system iin r lation•to.wells, buildings, etc. m st be plated on reverse side.} 4 i s r `NEW INSTALLATION: {No septic tank or seepa a pit permitted if public sewer is available within 200 feet,] P> KAGE TREATMENT [ SEPTIC TANK [ Size.----_r -I --�C----4�7----------, Liq_uj i .Depth --- --'_------.----- j Z capacityl-244---_ Type -4 r--FA$fRMateri �.CQ_AXAT'_ N,91.. �Gompartments ---------------------- Distance to nearest bit ____ ----+-------- --�---- -! --- Prop. Line --- _---_-_._. ' LEACHING LINE [$?"o�No. of Lines'._;'?__ ------ Length of each lin ----1 -------- ------Hta I Length ------ ---------- 'D' Box _ Type Filter Material------Depth Filter+at Material - ---- ------------_-__----.._-_-.- 7-1 Distance to`nearest: Well _ t:/_.-- '” ___ Founda#ion -119--------------- -Propertyi Line. SEEPAGE PIT [ ] Depth .___--------------- Diameter ---- Number _--- _________--------.__f:Ick Filled Yes E] Na ---------------------------- -- 4 Water Table .Depth ----------------- ock Size ------------------------------ t Distance to nearest: Well -------------------------------------- Foundation --------------------- Prop. Line _._._----_.. ......... REPAIR/ADDITION{Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- I Septic Tank [Specify Requirements] --------------------------------------------------------- ------------------------- ---- ----------------= - -- -l-----------------------------------'--: __,..---.---------------------- E ,h v Disposal Field (Specify Requirements) -----------------------=-------- -------------'" `---------------------------------------------}-4-=------------------------------- t l J� 1 -------------------------------------------------------- ------------------------------------------- � ----------------- ,� -- ------------------------- ------------. ------------- =:.__------ :------------ = .,. - ==-------- --- _ ------.� TDraw-existing and required addition 6n're e"rse side} 1 hereby certify that i have prepared this application and that the work % 11 be done in accordance, with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San 111oaquuuiin Local Health District. 99me owner or licen- sed agents signature certifies the following: " "I certify that in the'performance of the work for which this permit is issted, I shall not employ any person in such manner as to become stq ' Work 's Comp cation laws of California." i s Signed - " i..-,-. ------------------------------ Owner ----------------- ---------------- ---------------------- Title 1-.-----------------------------------------------{-------------------- 4 BY _ . (If other than owner) i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- I' ��' ` ------------------------------------------------------------- --------------- DATE -- f { — —r— BUfLDiNG"PERMiT"`ISSt�ED�': --`�"---------------------------- - =----------_----------------�--"'..`.�"�DAT�f -- ----------•--- -------- --------------• �! ADDITIONAL COMMENTS,----- ----- --- -------- ri _ �----------------------------------------------------------- i�U " . :, ------------ --------------------- - - --------------- ----- - ------- - -- ------------------------------------------ -------------------- ---------------------------------------- --- --- ------------------------ ----------------------- - --------- ----- - -- -- --- ---------------- --------------------- ------ ------ •---- Final Inspecti - --- - -------- ---- ------- -- - -- --- --------------- -- ----------- ------ ----- ---- ------ -- -- --- SAN JOAQUIN LOCAL HEALTH DISTRICT ,y E. H. 9 1-'6$ Rev. 5M