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FOR OFFI.CE USE: <br />li APPLICATION FOR SANITATION PERMIT, <br />(Complete in Triplicate) <br />- _11 <br />------------------------..... <br />......... This Permit Expires T Year From Date Issued <br />Permit No: _V -P_-- 5-1 <br />Date Issued ...?..Z..1.5 <br />.. !..Z_. 1-5 _..' t <br />Application is hereby made to the Son 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 />JOB ADDRESS/LOCATION ------ . ........ y %- ---------------------------------CENSUS TRACT _----------- <br />Owner's Name .... ........... <br />Are .-T -•----------------=----- __ ..................... Phone 8 ..t5:-7._2_._... <br />Address............ ---------- ------------ City ---------------------_- ------- ------------------------------------------- <br />Contractor's Name --------- ....... ------- ............. ...........................License # ...... ........... Phone --_--------_--- <br />Installation will serve. Residence []Apartment House[] Commercial oTrailet Court ;E] <br />Motel 17 Other ........................ .................... <br />Number of living units:.._,.,,, ....... Number of bedrooms ............ Garbc�ge Grinder ............. Lot Size . ........................................... <br />❑ <br />Water Supply. Public System and name ..................... ................................... . ............. V ....................................... Orivate <br />0 <br />Character of soil to a depth, of 3 feet: Sand E] Silt 0 Clay ❑ Peat 0 Sandy Loom -[] Clay Loam <br />Hardocin 171 Adobe ,Fl Fill Material ------------ If yes, type ............ ----------- <br />(Plot plan, showing' <br />NEW INSTALLATION. <br />PACKAGE TREATMENT <br />LEACHING LINE ( I <br />SE&AGE PIT [] <br />.1 <br />of lot, location of system In relation to wells, buildings, etc. must be placed on r e side.) <br />(Nb s ' tank or seepage pit permitted if public sewer is available w <br />it�hi,n�25t,) <br />.J rN11 <br />SEPTICT Size-.------------------ -------------- F - -----­---­------- <br />Capacity ................. <br />. <br />Y•T.................. Material ------- ... No. Compartments .................... <br />Distance to nearest- Well ................. dation-----------------._. Prop. Line ............. ..... <br />No. of Lines ..............Lengthof .................. ---------- Total Length __ .......... ----_-_-- <br />....... <br />0 <br />V Box ............ Type. Filter 'M of .................... Dep Material -------•-•------•--••-=-----------•----- --- <br />----------_ <br />Distance to nearest: .... .......... _ ---- Foundation --------------- Property. kine ...... <br />Depth ----- ........... . Diameter ................ Number ......................... Roc ed :Yes No C] <br />r Table Depth ­ -............ ........ Rock Size .......... <br />-------------- <br />Dlitance to nearest: Well ...................... --.1 ....... ­_Foundafion ------ ­.. 710 Line ................. <br />: <br />REPAIR/ADDITION (Prev. Sanitation Permit# -------_---­- .......... .: ----------- Date _----------_ ........•'---------) <br />Septic <br />1 --------- <br />Septic Tank (Specify. Re4uiiemerits) -----_--_--- ............................. ----------------------------------- -_---.--•--;----------- ------------- <br />keaAL_, we -------------------- .......................................... <br />Disposal Field (Specify -'Requirements) .................. ------------------------ * .......... <br />---------- * ------ <br />• <br />............................................. ..... ............................................. I ............... ........ <br />......................................... - ----------------------------------- <br />................ ........................... <br />[Draw exis ting and required addition on reverse si-a <br />- --------------------- ; ............. .......... ------ ­ --------- ­­ ------------------ ­­ .................. ----------- <br />e <br />I hereby certify that I he prepared this application and thait the work will be done in accordance with San Joaquin <br />YP <br />County Ordinances, State tows, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or liven- <br />- sed agents signature certifies the following.. <br />"t -certify that in the performance of the work for which this. permit Is issued, I shall not employ%"y person in such manner <br />as to become sub'rLct tr;WQ?gkrn*W1s Cwpensation laws of Caljfom[O." <br />Signed -- ---------------------------- D ------- --•----------'-------............ Owner <br />... .............. .............. <br />............... .......... <br />By ........................ ............................ -----_------------- Title ........ <br />------------ <br />(If efher thaK owner) <br />FOR DEP TME ME 0 <br />APPLICATION ACCEPTED BY ......... : ......:...r.......- .................. DATE .... ----------- <br />BUILDING PERMIT ISSUED;... ----------------------- 7 <br />-------------- DATE . <br />ADDITIONALCOMMENTS ----------------------------- ------ ---- -------- % ........... -------------- -------­-----­--­ ...................................................... <br />................... I .................................. <br />---------------••---•-••-----•---.-•-'.---------•-----•-•••--- ........................................ ............. ............ ... <br />............... ...................... ..................... ------- _ ---------------­--- ............... ............................. ----------- ........................................ <br />oe - <br />..................... 2 ..................... rr- ---.1- ------- -----------.----------------------------------------------- <br />. -.-..--------------- <br />Final Inspection by- ----------........-..... ....------------ -------------- <br />......... I ....... <br />...Date,-A7,3r.............. --------- <br />ICT <br />ZiAr4 JUAWVIN LV%.,-kL r]C^Llrl <br />E. H. 9 1 -'68 Rev. 5M:: <br />P <br />4 <br />