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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ----- --------- ------ ' (Complete in Triplicate) - � Date issued ---7��--� ----- p - This Permit Expires 'I Year From Date slue - 1 the work rein Application is hereby made to the San Joaquinnian�e withcal ealth Counbis tytOrd Ordinance No. 549 and existing Rules rict for a permit to construct and tand Regulations. described. This application is made in co p S6 ,.+ - - --------------CENSUS TRACT JOB ADDRESS/LOCATION . -=/ ;` ` ?` - -- - ------- -------------- Owner's Name Phone ) � c -------- City ---- - � -------•---- ------------- IX ------------ Address ------ ti ��y •--- � � 3� '2�--_ Phone ----------------------------•- Contractar's Name - ----"¢ ' -- License # - r e Apartment House❑ Commercial ❑Trailer Court i Installation will serve: Residenc Motel ❑Other -------------------------------------------------------- Number of living units:_-----C-- Number of bedrooms ___ -_----- GrinderLot Size -------------------------------------------- private Water Supply`:. Public System and name -------------------------- Clay-Loam I Silt Clay Peat❑ Sandy Loam ❑ Character of soil to a depth of 3 feet: Sand'❑ ❑ Y ❑ jHardpan CX Adobe F1Fill Material ------------ If yes, type - --- 1 ` ,tt y buildings, etc. must be placed on reverse side.) } (Plot p[an;;showing�size'of lot, location of system in relation to wells, in �t ermined if public sewer is available within 200 feet,) NEW INSTALLATION: � (No septic tank or seepage p' p Liquid Depth ---------- PACKAGE TREATMENT ^[ ] ' SEPTIC TANK [ ] S;ze----------------- q = Compartments ---- - ------•----- ial Capacity -- TYpe ---------------------------. e - h Fondation --------- ------ Prop. Line ---•------------•----- IT Distance to.-nearest:-Well ....-__=.yam ( -------- Total Length ----------------•----------- ' LEACHING LINE [ ] No. of Lines ----------------- Length of line__-------------- D' Sox ___-- Type Filter Material _---`--------------Depth Filter Material -------------------- ------------------------ Iter T .. v. Property Line - � Distance to nearest: Well _------------------ --' Foundation ------------------------ p � _ Diameter �- ------------- Number -------------------- ---- Rock Filled Yes ❑ No I❑ t SEEPAGE [ ] Depth -. v>. �,-.� I ' Rock Size -------------------------------- WaterTable Depth ---------------------------•------------ 1 ---Foundation ---------�- -------- Prop. Line _..---------••--•----- Distance to nearest: Well----------------------==------------- l REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------- .----------------------- --------------------------- =-- -- ------------------------ --- ------ Sept•IcrTank}(Specify Requirements -------- - Disposal Fibld (Specify Requirements) - --------------------- ^--�- - - ------------ ----------------- --------------- ---------------------- r (Draw existing and required addition on.reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. dome owner or licen- sed agents signature certifies the following: G "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in suchmanner as to become subject to Workman's Compensation laws of California." ----- - Owner I Signed .--------- ---------- C �D . - ---------------- - Title --------------------- By ------------------- �`` ----------------------- -- --- (If other than owner) FAR DEPARTMENT USE ONLY DATE -----APPLICATION ACCEPTED BY .q_ -- --------- ---------------------- r ------ --------------------------------------- ----- ---------------------- DATE --- ------- ------ - BUILDING PERMIT ISSUED ------=--------------- -- ---- ---• � ADDITIONAL COMMENTS ------------- ------- - ------ ------ ------- - ---- ----------------- -- --------------------------------------------------- ` Date Final Ins pection b = -------------------- 4 � � SAN JOAQUIN LOCAL HEALTH DISTRICT c W 0 1-'68 Rev. 5M