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FOR OFFICE USE:' APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- Permit No. -)e' <br /> ---------- ------ <br /> _ <br /> (Complete in Triplicate] <br /> This Permit ExpiiC!Vll-Year'Pom Date1ssued Date Issued 5...�a_ �� <br /> Application is hereby made to the San Joaquin Local Health District for a permit,to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> L� FR - <br /> JOB ADDRESS/LOCATION ._.�5�.�_�.__.-_�......� - �--- <br /> ------------------------- ----CENSUS TRACT _���._._.... <br /> Owner's Name --------------DE—NIVUS-----------f- 1.t N7r--------------------.------------------ <br /> ------------------Phone -�SZ------^--4�--7��_ <br /> � 5 <br /> LCit �Address -------- -- <br /> Contractor's Name _ - ._... .PT�.L...,?� R\}.lC.�.__.License #ZZ---,51-_(--- Phone 6v2__~.. _!. . <br /> Installation will serve: Residence 01�partment House 0 Commercial ❑Trailer Court ;❑ <br /> f Motel ❑Other -------------------------------------- ---- <br /> Number of living units:----(------- Number of bedrooms ._. --Garbage Grinder/_A Lot Size -----::Z <br /> Water Supply: Public"System and name ----------------------•--------------------------------------------------------.------------------------------Private [ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam •Q' Clay Loar-6 [D <br /> S LT•. - 3 <br /> Hardpan ❑,, Adobe E] Fill Material . ��_ . If+yes, type __.____-._._ <br /> (Plot plan, showing si'ze'of lot, location- of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if,.�ubl'c sewer is available within 200 feet,) <br /> PACKAGE TREATMENT {,'] SEPTIC TANK S''rze ._ -4.�- - S_1�_rr._---- Liquid Depth ---- ---i-_---- ---- <br /> Capacity --- Type !j A-[ - Material-69MR T-No. Compartments _ ,,,......._.... r' <br /> istance to nearest: Well -------- —------...._.Foundation ._.. (t=.._ Prop. Line -------- <br /> LEACHING <br /> c + • .. <br /> LEACHING LINE [ No, of Lines _.____.-�_..._------._ Length_ of each line-------,7�-__--- Total Length ,.._� ................ <br /> 'D' Box '/..E�5_ Type Filter Material .CI.QGK._.Depth Filter Material ----- -f ----------------�............. <br /> Distance to nearest: Well Foundation �Q...�___- Property Line ._fir... �`....... <br /> SEEPAGE PIT [� Depth•-,�r�s______________ Diameter --'r- .._ Number -- ------------------ _..__. Rock Filled-, Yes P,-- No 0 <br /> Water Table Depth ------15Q----------------------------------Rock-Size//7__ <br /> =� /+ <br /> Distance to nearest: Well f __�...................•..Foundation _- --- ... Prop. Line ---_r.' _•. <br /> r� <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date -----------------------------------11 <br /> SepticTank (Specify Requirements) ----------'------- ------------------------------------------------_-------------------------------------------------------------------------- --------------------------- <br /> DisposalField (Specify Requirements) ------------�------------------------------------- -----------=------------------------------------------=------------•----------- <br /> ------------------------ <br /> 1 <br /> ............................ t.._ wY... w�_.___..Y., ------------------------------------- <br /> I- <br /> ._..__..._......_.------- �__. i <br /> ,.r Ey (prow existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances; State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies-the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to beub' t to Workman's Com t' n laws of California." <br /> co <br /> Signed - - ------ � ---------------. Owner <br /> By ---------------------------------------------------------------------------------- Title ------------- ------- -------------------------- ------------------- <br /> (If :other than owner) <br /> FOR DEPARTMENT US15"ONLY <br /> APPLICATION ACCEPTED BY ---_--- 1....� t------ - ----------- --------------------------- DATE .... -------------- <br /> 7: <br /> BUILDING PERMIT ISSUED --- -------------------------------------------------------------------------------------_.--------DATE-------- -- -------------------------------- <br /> ADDITIONALCOMMENTS ----------- ----------------------------------------------------_------------------ -------------------------------------------- --------------------------- <br /> ---------------------------------------- -- =-- --- ----------------- <br /> - - -------------------------------------------------------------------------- <br /> -------------------------------------- ------ -- ------------------- - ---- ------ <br /> --- -- -------------------------------------------------------------------------------------------------- <br /> ------------------------------------ --- -- - -- ----- ------- � <br /> Finally j Date -------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />