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FOR OFFICE USE: � APPLICAtION FOR SANITATION PERMIT �� - °._.. . Permit No. ..................... .............. ... {Complete in Triplicate) ........ ......• .._... ---------------- Date issued !,/� .. -- •••-• ........... This Permit Expires 1 Year From Date Issued ............. Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordi once„No ' and existing Rules and Regulations: JOB ADDRESS/LOCATION .._. . �` • .........CENSUS TRACT .............•---•---•--- ....Phone. . Owner's Name Address �. �........ �'" ._.. city - ....... ..:............ . Contractor's Name .................. .. . . -... License # .: �7--- Phone . :.--• -- Installation will ser -•- -•- ve:--�- Residence-iAportment House❑-Commercial`❑Trailer'Court''❑ Motel ❑Other -------------------------------- -------• - r ! -�--��.�,:.. Lot Size _��-.�---.. .-- ----�•--------•-- Number of living' units:-...1 ._... Number of bedrooms _-.�rGarbage Grind Private ❑ Water Supply: Public System and name -..•.................................------ --.... y. . . - ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sand Loam C1a Loam Hardpan ❑ Adobe ❑ Fill Material ........-.... If yes,type ----------- ----•---• -----• buildings, etc. must be placed on reverse side.) {Plot plan, showing.size of__l_ot,_Ipcgtion of-ofto wells, ,1 NEW INSTALLATION. lNo septic tank or seepage pit permitted if public .sewer is available within 200 feet,) PACKAGE TREATMENT [ � SEPTIC TANK. ] Size---•---------------=•--- • ..._.._..._. Liquid Depth .----.._.. •.......__.-..� Capacity .. Type -• ---- L Material----- No. Compartments .....................:Ul --_.......Foundation ......--.---•.-....... Prop. Line ...............16 1 Distance to nearest: Well . ........... ... l - f r . LEACHING LINE [ ] No. of Lines . --. - Length o each line ......... -•----' -. -Total Length ` D Box .._.. .._. Type FilterWateriai ..............- depth f=ilter Materia'c__......_...._ :: ::::::::::::::_,..� ,ip � t� �tia 1 . 4, ? Foundation ................. ...: �operty Ling --- •--'No Distance to nearest: Well ---...- p Depth .. _ Diameter ! .. Number . ...... ................... Rock Filled ,Yeso.[i SEEPAGE PIT [ ] 1p - �---.. -`---•---•-•-- i Wbter Table Depth -------------------------- -----------------Rock Size _ ----•- ---••- ..... il ----•-•-•Foundation ... ........ ....... Prop. Line- -..---- ........... Distance to nearest: Well -..-_.--..___.------ . .------•--------- REPAIR, ADDITION(Prev. Sanitation Permit# -------- ---------------- -- --- -�' Ilk to __......_.... r I Septic Tank ISpecify Requirements) Disposal pec .. _ /._" Dis l Field (Sify Requirements) -- _ .. ` i p - . ------- ----------- [Drdw existing Fandor_eq.uired''addition on reverse side) l R f I hereby certify that I have repared`this application and that the work will Le done in accordance with San Joaquin County Ordinances, State Law�,s�dfid Rules-anci-Regulations�=Il al Health District. Home owner or licen- sed agents signature certifies the following:I certify that in the performance of the work fL which thispr , not employ any person in such manner as to become subiect to Workman's Compensation laws of California." - I _L. Owner Signed -:-. � e----- FTitle . .... ... .................. .•- -.... ?eWrowner) ................... By Ilf of r MENT USE ONLY APPLICATION ACCEPTED BY ..... - ------ --------- ------ .. DATE .- ..,3."_p` .... ..._�._..... I BUILDING PERMIT ISSUED - ...._ ADDITIONAL COMMENTS ---•........................... ....... ......-.......... . ... --.....- date ... - ... �. Final Inspection by: .--- - -- -- - -. SAN JOAQUIN LOCAL HEALTH DISTRICT 7/72 3 M- .