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FOR OFF19E USE: ...... ...........................11........ ------------ APPLICATION FOR SANITATION PERMIT --------------------------------------------- (Complete in Triplicate) Permit No:4� ------..................................... This Permit Expires I Year From Date issued Date' Issued Application is hereby made to thOaMnRaquin ocal ealthh District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: :t - f -1----- T ----------- JOB ADDRESS/LOCATION ---- /W1 16;t-Crf- r �7 el -- 4- .. rCENfiSUSAPAC Owner's Name RIP_IT-1_...W./owe ............... ------Phone.......................(%P-------- -(---------- ........ ------ Address -----------------�7. City -/;?/ wll/ ------------------ Contractor's Name ---Zp,-I:-_-• -_04.11? F .... ------------------License #apv� Phone Installation will serve: -- Residence E]Apartment House❑ Commercial [Trailer Court 0 Motel 0 Other .,569/e hevj,e Number of living units:... ........ Number of bedrooms _....._._.__Garbage Grinder -- -- ---- Lot Size 461e,�?eff'e --------- ---- ---------- -------------------------------------- --------- ------------ ................Private Water Supply: Public System and name - Character of soil to a depth of 3 feet: Sand)d Silt 11 Clay D Peat E3 Sandy Loam E] Clay Loom E] Hardpan E] Adobe El Fill Material .----------- if yes,type...... ....._............. c!p (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 permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK[ Size. X---- -5YY ;;�--- -- ----- Liquid Depth -.--Y"-------------- Capacity Type -Ae_eW. Material JP /M Ic No. Compartments .?7�............... 6-�o/ Of Distance to nearest: Well ----- -------____-----------Foundation / - --- ------------ Prop. Line ....... LEACHING LINE No. of Lines .------ ------ Length of each line 01 -1 - ---- Total Length .---'PIP 'D' Box ............ Type Filter Material 0445- Depth Filter Material -/9-0------------ --------------- Distance to nearest: Well —_-----.- Foundation ....l .............. Property Line __67--------------- SEEPAGE PIT Depth ----- - Diameter .---- -------... Number -------------------------- Rock Filled Yes [3 No C] Water Table Depth ................................................Rock Size ---------- -------------------- Distance to nearest-. Well ........ ...... .._......_.--.-,--Foundation ---- --- ----------- Prop. Line ... -------- --------- REPAIR/ADDITION(Prev. Sanitation Permit# _-..... --------------------- ------ Date ---------------------------------- Septic Tank (Specify Requirements) ----:......................... ......... --Disposal Field (Specify Requirements) raR....;5.9Aj6F......yp._V.,AX --------aN ..................... --- ------------------------------- ....... .............:........... ........................................................................................................-1- --_--------------- ---- - ---- -------------------------------------........------------------------------- - ------ -------- ---------------------------------------- (Draw existing and-required addition an reverse side) I hereby certify that I have prepared this application and that the work will be done In accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: 1� "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 become subject to Workman's Compensation laws of California." Signed Owner (If other than ownea/ Title -------------------------------------- ---- ----------------- FOR DEPARTMENT USE ONLY--- ._ tow, APPLICATION ACCE BUILDING PERMIT ISSUED ------ ---------- . ED BY. .....................----------------- ---- -------- DATE --------------------........ ............I......... ....... ADDITIONA M E ----------- ................... ----- -------------- ........ ------ ---- ------------- ........__------------------- ------------- ........................ --- ---- ---- ------------------___--------- --- ------------ ----------- q ----------------------------- ------..... ... ......................-I------ ------- ----------------------------......................... .................I---------- ------- --- ------- ...... . ................ ----------I-------------- ........ -- ---- -- ------ ------ ................... ---------- ---------- ------------------ ------e --�6 Final Inspection ---------------------------.-_.......Date r SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6R Rev. 5M