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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT '------ ------------------ --------- Q-------------- r \' {Complete in Triplicate} Permit No. : :- : ____ __________ This.Permit Expires 1 Year From Date Issued Date Issued _J :7/� '---- Application is hereby made to the San Joaquin Local"H5altlf,District•-for-a-permit to construct and install,the—vmk-°here'n described. This application is made in cJP 'anc�LFL with rdinance No. 549 and:ezisting Rules and Regulations: r J08 ADDRESS/4A, O L_� ...... -----------------------i-------- ----CENSUAIZA-CT.�_= = Owner's Name Phone----- Address > ------- ---- -------------- City ---�` ------- --------------------------------------- ----------- ---- Name _ `- -- -- . -s,�-+---- ------.License#� � Phone --------------- - ------------------- - Installation will serve: Residence Apartment Hause Commercial:[Trailer Court Motel ❑Other ------------------------------------------; 01 Number of living units:---r_____ Number of bedrooms_--,-?-_._-_Garba_ge Grinder .._-_------- Lot Size _________________________ .-._ - - ------------- Water Supply: Public'`System and name ------- __ ------------------------- -------------- ._.__________- ------------- Character of soil to a�depth of 3 feet: Sand'0 Silt FClay .Ej Peat E ' Sandy Loam Clay Loam n Hardpan ❑ Adobe Ej Fill Material ------ If yes, type --________-______ (Prot 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------------------------------------------------ Liquid Depth -------------------------- i -------------------._ --_+ Capacity -------------------- Type -------------------- Material---------------------- No. Compartments V Distance to nearest: Well ------------------------------------ Foundation ----------------------- Prop. Line -------------:...--=�-- (A] : LEACHING LINE [ ] No. of Lines ------i' --l ength-of each line------- -------------------- Total Length :--------- ----.-....------- 'D' Box ------------ Type Filter Material __________________ Depth Filter Material Distance to nearest: Well ------------------------ Foundation Property Line -----":� SEEPAGE PIT � Depth c �' � � •'` [ ] p Diameter t__:_________"^Number ___----_____�1t._____- Rock Filled Yes No Water Table Depth ______________ f P i --------- --------------=--------Rock Size -------------------------------- Distance ------ ----------------------.-Distance to nearest: Well ____ _________________!------------ __Foundation __.____ Prop. Line -------- ........ ------------- -- REPAIR/ADDITION(Prev. Sanitation Permit# -------..------___ -- --------- Date r____________ _ -----_) - -------------- - ------------- Septic Tank (Specify Requirements)3' ,.-------------------------------------------------- Disposal Field {Spec'fy Requirements}N� -- � --- - ------ �I = �------- - ----- - ; _ z -T - --------------------- ---- (Draw existing and required_addition'on reverse sdel I hereby certify that I have prepared this application and that the work will be done in accordance with Sam Joaquin a County Ordinances, State Laws, dnd Rules artd Regulations,of the)So Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that i e performance of the work for which this permit iis;issued, I shall not employ any person in such manner as to become u )e t to Workman's Comp anon laws'of California." Signed ---------- -- -- --- ---------- --- By - Owner Y / BY r< Title 4 �� Ir (I other than ow er] ti _ FOR .DEPARTMENT USE ONLY APPL-ICATION—ACCEPTED-BY:-.. . --�-- _ t BUILDING PERMIT ISSUED ------------------------------------------ - " DATE 7------ -------------------- ADDITIONAL COMMENTS ----------------------------- - -- - - --- ------=--------------DATE ------------- ----------------------------- -------------------------------------------- •------------------ ------------ ----------------------------------------------------- ---------------------------------------- ----------------------------------- --- --- ---------------------------- -------------------- ---------------------------------------------------------------------------' ------- ---- - - ------- ----- -- Final - -- / Inspection by: ------------ -- -------------- 4 ------- ------- - ---------------- -------.Date ------- ! - - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.