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FOR OFFICE USE: ' .`�� APPLICATION FOR 'SANITATION PERMIT ,. WT s. ' '- Permit No: _ Q__3 . ------- (Complete in Triplicate} ' ---------- ----- 'Q t 11�r Y rr Date Issued &-- T� -- - --__ This Permit Expires 1 Year 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 Cop Ordinance No. 549 and existing Rules and Regulations: QN CENSUS TRACT ------------"------------- JOB ADDRESS/LOC .- �/ -. --- � I P Owner's Name G ------ = Phone -i-�- - r Address ------ ---------------------------------_ `� ------ Contractor's Named --------------------------------------.License #/C�.-�� _ hone /_�._.�----------- Installation will serve: Residence [K Apartment House❑ Commercial ❑Trailer Court '❑ r i Motel ❑ Other ------- ---------------------------- Number ----- ------ - i( -` -1 t-P-------------- hlumber of living units:___------ Number of bedrooms -----Garbage Grinder /LG:.G__ Lot Size - Water Supply: Public System and name --------------------------------- -- --_•---------------------------- Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt.❑ Clay ❑ Peat ❑ Sandy Loam ❑ " Clay Loam Hardpan El AdobeFill Material _.-- ------- If yes,type ."-- 6\ [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 availablewithin 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'f l Size--------------------------------------- -------- Liquid Depth --------------------------- k Capacity ----- Type -------------------- Material---------------------- No. Compartments ---------------------- - P Y ---- ------- YA �~ Distance to nearest: Well --------- ----------- -----------Foundation -----.--__._---------Prop. Line --------------- ------ - LEACHING LINE [ ] No. of Lines ------- ----------- ---- Length of each line---------------------------- Total Length .---------------.------------ 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- 1 Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------•-•--- SEEPAGE PIT [ ] Depth - Diameter ---------------- Number ----------- Roc --------------- - Filled Yes 3❑ No i❑ --- ------ Water Table Depth -------------- Rock Size ------------------- -•---- l Distance to nearest: Well ----------------------------------------Foundation ----------- 4Prop. Line --_------- ...... REPAIR/ADDITION,,.Pre.y, Sanitation-Permit i# ----------------------- Date ---------_------•---------------- 1 Septic Tank {Specify Requirements) --- ----- ----- ------------ --� w ------ -----------•------- I � �� ------------------�---i ------------------------------- o� Disposal Field l �ify Requi fentsl _ _ i e1 - , �/� 9 - ------------ t - - F r -------------- --------------------------------------------------------- (Draw existing and required addition on reverse side) s" i I:hereby certify that I have prepared this'application-and-that-the-work-will--be--done•-in--acc-wdance with San Joaquin ions of the San Joaquin Local Health District. Home County Ordinances, State Laws, and Rules and Regulatowner or licen- sed agents signature certifies the following: "l certify that in-the performance of the work for which this permit is iissued, E)sh`all not-einploy any iltion in such mariner as to become subject to Workman's Compensation,laws of California." f t - Signed---------- ------ - --- ---------- '---- ---- _ ------ Owner - Signed l-. --- - - I. _ F J a 1 ' tJ---------------------------- - G By Lac✓Z ,� �4 x e T'tl �� ter than owner} �. < .. _ . �,_ : .r ... _..._., �.. FORT.DEPARTMENT USE ONLY .- - NLY .- v` � o L -- APPLICATION ACCEPTED BY _."- - DATE __.. -"-----------.--•-----------------" BUILDING PERMIT ISSUED -- - ---- , - ----DATE ---------;---- --------------- --------------------------------- ---- { ADDITIONAL COMMENTS ------------------------ -------------- _- •. _ ------------------------ = -------------- --- ------------ __%- ---- -------- -------- --------------------------- 70.- - _ ' V 1 \� 1 J„ _-4------_ ---- - - Final Inspection b -- ------------------------------------ - --.Date -_. SAN JOAQUIN JOCAL HEALTH DISTRICT E. H. 9 ---�-f-='6$ Rev. SM ti's