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t� FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. .............--...................._..............-.... (Cornplete in Triplicate) .......................I....._. ........................ Date Issued ..s... �'?.::2r This Permit Expires 18ear From Date Issued Application is hereby made to the San Joaquin Local Health 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: 4� ,..._.........:.........CENSUS TRACT ..._.._...._.............. JOB ADDRESS/LOCATION ... ................ ...................... -. - ' T .__.. .............phone..................................... Owner's Name ....... , ... ................................... Address ....�.#.: ...... - ... City ...- �'...............................on .. _ ...... ..License # ./ ... Pone .............................. Contractor's Nome .... . ... .- �' Y Phone Installation will serve: Residence Impartment House❑ Commercial:Trailer Court .0 I Motel ❑Other .............. . ------.... �. Number of living units:..-_.-.r...- Number of.bedrooms ----------- Garbage Grinder ..........-Lot Size_.-••..-•:••-------••••- ------•---Private Water Sup.pl"y: Public System and name ................••------------ --•---- -...--------------------•---•----------••------....------•-••--- Character of soil to a depth of 3 feet: Sand ❑ t❑ Clay ❑ Peat❑ Sandy Loom fl Clay Loam Hardpan Adobe ❑ `'F+II Material ............ If yes,type ........._--_--------------- f (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,) l ] Size _ ...• . Liquid Dept PACKAGE TREATMENT SEPTIC TANK ) •---••----...---•••- Type ...............:.. Capacity .. Material---�:F............-• No. Compartments ...................... . - i Prop. in ...................... Distance to nearest- Well ...___.'......................Foundation .._.........:......--- o Line i ............. LEACHING LINE No. of Lines ......................... Length of'edrh line-------------;..'=-------... Total Length ........................... (� 'D' Box _ Type Filter Material ..Depth Filter Material •.......• .. _ Property- ........................ Distance to nearest:Well .` :::-..:--- Foundation ...^.. ... `-=_. Pro a line Depth Diameter ............... Number ---------------•••-•........ Rock Filled Yes'❑ No Q Z SEEPAGE PIT [ p ._..-_.._._ . ..Rock Size Water Table Depth ----_------ = Distance to nearest: Well ........................................Foundation ..-----=.._. ..... .Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit df` Date .......................----•--•-••j .. ......... .... Septic Tank (Specify Requirements) ---................................ ;------- ........ ............. -•---•.................. _......... Disposal Field (Specify Requirements) ... --- 7JN . - ------------------------ -----. ...............................-.......................... .................................. (Draw existing and required addition on reverse side) that I have re ared this cipplication and that the work will be done in accordance with San �loaquin I hereby certify P P t County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licew sed agents signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall not ensploy any person in such manner as to become subject to Workman's Compensation laws of California." Owner Signed Signed .-----------................1.----------...----- By ..... ............ a .... .ther..--•--....-. Title ..................................... ........................... •----- (If othan owner) FOR DEPARTMENT USE ONLY ! . APPLICATION ACCEPTED BY . .................................................................. DATE ._..---......_..._._...... BUILDING PERMIT ISSUED ....DATE ........................................... ' ADDITIONAL COMMENTS ............... •-•......----•---••------............-•.....--.---........----•. ....•--•.................. .._.. :_........ ---..-.. ...-----•-.................---......--_..... --- _ .... ........................................... ............... is Date ................. F e - Final Inspection by: - - - ��.........................•-:•-...-------•-•-• a SAN JOA4UIN LOCAL HEALTH DISTRICT 7/72 3 M