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w FOR OFFICE USE: : APPLICATION FOR SANITATION PERMIT ------------- Permit No.. ---------- ------------------- --------- -------------- (Complete in Triplicate) = =------------------------ ------ Date Issued e = Ta This Permit Expires 1 Year From Date issued -w 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. 5A9 and existing Rules and Regulations: JOB ADDRESS/LOCA`TION --- _ 3 = `��f ^ I��f4C--------------- --------- CENSUS TRACT ------- ----- -------------------------------------- - Y Owner's Name _ - 1 _ - --------------f-' =�_�Rhone -- `� ,- ! _ Cit '-- --�'-'-----------------------------•-----------•----•-----•- Address ------ - ------1 1 ---- -_C�,-_HP �: --------- y --- i ' �"'`==r ---=--------License # --------,- --'--------- one -------- -----•-----------•-- Contractor's Name _._ ll` ---------- - ---------------- Installation will serve: Residence partment House`❑`Co menial :❑Trailer Court ❑ -Motel ❑ Other -----f/ -------------- ------- ------- 44�� ----- � ! -- ', �--- Lot Size - -- ---: ----- Number of living .units:-_._ ___.j_Tqu-mber of bedrooms t -_--Garbage Gr _. Water Supply: Public ------------------------------------------------ 'ter ________ _____________Private PP Y' �' System �nd�:n�rne=�=__ --------�- ----�- - --=�=_-�"-------- - -------- ------•--------------- --- CI ` ' � '--- 1� f -_ .._..._ - i - a Loam Character of soil to a�ydepth of 3 feet Sand y -� Silt❑ l ClayeQ,,j Peat❑ Sanely Loam ,❑ y i ❑ _ tia . x' 31 Hardpan ❑ Adobe '[]i"'Fill''Mater'is _. -- Yet if YPe l s t r. 3` 1 (Plot plan, showing size of lot, location of system inn relation #o,wells, buildings,-eta•-must--.be placed; on reverse side.)1 �NEWINSTALLATION:. �'(No septic tank or seepage pit permitted if public sewer is avaiiabPe wihin 200 feet,} p - Liquid De #h ------------------------- PACKAGE TREATMENT fi ] SEPTIC TANK'[ ] ;� Size-------------------- ------------ q p i or Capacity Type ;----------- Material--- ------ --- No. Compartments ,C € -Foundation --- ----------`;----- Prop.Gine Distance to nearest: Well _____ _ - .:____________________ LEACHING LINE j ]'. No. of-Lines ------------------- g i , -- ' aTotl Length ---------------, --- L n th ,of each line---=---- ------------ � 9 i 'D' Box ----- ------ Type Filter M terial ---- "Depth Filter aterialf --------------'•--------- ' ! Distance to nearest: Well Foundation --------------- ------- Property Line ____-_____a_------------ rN a Depth -- Rock Size 'sl ' es ❑ f No SEEPAGE PIT [ l P -- - - --- Diameter ---------------- Number ----------- -- -- F- __ Rock Filled ') """�"�."_....`".-�w�iFoundation _ �• --- � � ----------•- �`---------f Prop. tin i ` Water Table Dept _----. `r Distance to nearest: Well ------ e --------'---------- J REPAIR/ADDITION(Prev. Sanitation Permit# _____________ -------- Date - 1 i Septic Tank (SpeCi,fy Requirements) - --------- ---'- -------�--------------- ------------ ---------- ----..__--- ---------- --�- ----�.. .- _ - Disposal Field {Specify Requirements) ----�/ �`-!- 1-1 - -----�------F�10—� 'i--- � - 4 - b� ._________._a___----�..n.____�_-_______.__ ---------------------- � 3 ------------------ ----------------------------� --'.- -- that the work wil---f----- --------- ---'-------- --- - __.- fired addition on rev. _ ' I have prepared this application and 1 (Draw existing and required reverse side] ' I be done in accordance withFSan lJoaquin I hereby certify that p p Pp ' County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Ho a owner ,or licen- sed agents si ture certifies the following: "I certify t in the pe, rmanc of the work for which this permit is issued, I shall not employ any person in sucfti manner as to bec a subject jto rkm 's Compensation laws of California." } i Si } ifit�@- Owner -- Title -- ----------------- --------- --------------------- BY ----------------------------- --------------- ----------------------- t ` Q ---------------' (if othee than owner) ' i FOR .DEPARTMENT USE ONLY �} _ -----. DATE -----� _. APPLICATION ACCEPTED BY }-- R - - ------------------------------ r '1 t -._ BUlLDINC PERf�ilT f55UED.. _.. 1 = ^_- __r__�._DATE �"� =" ADDITIONAL COMMEa-_ :--1:R- - --r= �- ;----- - ------------- _ _. ------------ . ----------------------Final !ns Date -. SAN JOAQUIN LOCAL HEALTH DISTRICT j E. H. 9 1-'68 Rev. 5M