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FOR OFFICE USE: I P APPLICATION FOR SANITATION PERMIT Permit No_ ______ ____ (Complete in Triplicate) i ------------------------- _._______-____________ f This Permit Expires 1 Year From Date Issued i Date Issued ------------- Application is hereby made to the San Joaquin Local Health District for a permit to construct nd install,the work herein described. This application'#is made in compliance with County Ordinance No. 549' and existing Rules and Y' 3 Regulations : CENSUS TRAC � 51JOB. ADDRESS/LOCATIONl__ . ---------- -- Owner's ------------------------ - --------- '=Phone ------ =---------------------------- 177-C ---------------- --•---- } -- ------- _ /�j z Address`_:__-f- --- i Q �• UI+��J ,DW City �"i k ' , ! r --------=--- ------- ---- ---= Contractor's Name ._I__-PAIVA_ _____ rlC__ RVI[CE-License 0:1 ________________ ____ Phone "____.____________________.__ `Ak Installation will serve: Residence eAlbbirtment House❑ Commercial :❑T'9i[er Court k❑ -•--•-- ------- g �--- Motel Other _._�� -- - -- -g rte,_ . Number of livin units:___ Number of bed,rootns .---________Gorba a Grinder __ tom'__ tot Size4CIRi�&&�___________ Water Supply: Public System and name 'i------------------ ----------------------------- '' i.. `'.Private r } t p � Hardpan ❑•: Adobe'❑ Fill MaterialkoiI dy Loam tClay Loam "[] Character of soi!to a de t�sof 3 feet: Sand� Silt Cla PeatSa yes, type;--________._ ---------------- L I tl (Plot plan, showing size of. lot, location of system in relation to wells, buildings; etc. must'belaced'}on reverse side.) NEW INSTALLATION: (No septic tank or seep pit permitted if pyblic sewer is available within 200 feet,) F� PACKAGE TREATMENT { SEPT IC, Size_G `__ .?�________��!9 ?_ quid Depth __-_3V_____________ Capacity ---- Type88ECRj-Material_6QACR—r 77-1 Ro.,'.�CCompartments ...... I {``e a � "� +� Distance to nearest: Well ------ ____�-:---------Foundation __��_____ ______ Prop. Line __�:._____.....- LEACHING LINE [�No. of Lines ____-__ Length of each line_-__- �s _�__- -___- T�tai Length ____�f �.______.. I t �i ! t '_ " �""Type niter Material0_{" 1___Depffi Fi1e�IV13teiiiti—;til- _______i............. `D' Box � �-<-- --•- tsy\'i�w;I .-�� v' "� is A i S ��.-, Distance to .nearest: Well' ____ ___ .____ Foundation 1 _" "____ Propbrty Line __...r.............. v.1w„s v.tq I - * fl1 .T=fvVt SEEPAGE PIT [ ] 1 Depth ______________ _____ Diameter ---------------- Number'I -- ----- Rock Filled Yes ❑ No i❑ Water Table Depth -------11----------------------------------------Rock Size -------------------------- ------------------Foundation _____---_-____--%Prop. Line ..._._..__._...._. Distance to nearest: Well _____________________ .___ / ermit`# -------- ----------------------------------- Date -----------------------f�-----} REPAIR ADDITION(Prev.(Prey. Sanitation ✓ Septic Tank {Specify Requirements)-----------------------------;-- --------------------------------------------- [ � Disposal Field (Specify Requirements) ------------------------- ---------------------------------------------- --- •------------ ' ----------------- --------------- , V ; -------------------------------- ---------------------------------------------------------- -------------------------------------------- ------- ------------ - ------------- --------------------------- = f ---- --------- =='-- - - - ---------------- -- - - J [ (Draw existing and req6,ired addition on reverse side) [ hereby certify that f have prepatred this application ands-that the work will be done in accordance with Sanj ao quire , County Ordinances;State Laws, and Rules and Regulation31 -•-of the San Joaquin Local)Health District. Home owner,or'lic,en- sed agents signature certifies the following: "I certify t in the performance of the w k for which this permit is issued, I shall n t employ any person in. such manner as to be subjee t Workman's Comp sati.on laws of California." Signed -------- •--. Owner BY --------------------------------' %R_0!Title -------------------------------- (If other than owner) 'FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---`�7tff-0---t--_`--x-- _--------------------- --- �- -- --- - -------------------. DATE -- -------'---- '•-�------- BUILDJ.NG PERMIT ISS.UEP._._._,_.za_—! -._ ��,Tu_ • 1 = - ,x_.,:___ :=:=::DATE -:r --=--------------`.. ADDITIONAL COMMENTS :_ :" ` --- _--_-- _---- ---------� 1-- -------------- - ------- ------------ ------------------ --- -- -------- - --- -- --- ----- --------- ---------------1--------------- -------------------- Final Inspectio - ----- - .--`Date ----- A � 1 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M