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`Fol; OFFICE USE: APPLICATION FOR SANITATION PERMIT ` Permit No. .�-�`-r -------- (Complete in Triplicate) ------------------------- ---------- Date Issued -q-"---- ---7 u (� This Permit Expires 1 Year From ate issued --------- t it to work A lication is hereby made to the San Joaquina+lrlHle Health Di tOrd nan a Nom549 and existing Rules stalnd hRegulationsherein for a pp application is made in compliance E described. This app l CENSUS TRACT -------------------------- - ---------------------------------------------------------- J013 --------------------------------JOB ADDRESS/LOCATION ----- ��/ Phone! Owner's Name - IA�7-1'------- .�WA _ Cit �o�'- M ------------------------------------------ --- --- -------- ------------------ ----------•-----•--- !!/l License Phone Address # ��3 Contractor's Name Commercial ❑Trailer Court l❑ Installation will serve: k .--ResidenceZ Apartment House❑ Motel ❑Other -------------------------------------------- r Number of living units:-----/----- Number of bedrooms cL--.-Garbage Grinder �/Q---- Lot Size Qa------- --------- DU- - --------------------------------Private ❑ --- -- ---------------- Peat❑ Sandy Loam ❑ Y Water Supply: Public System an name -------------- - ---- --- Clay Loam:❑ Character of soil to a depth of 3 feet:. Sand'❑ Silt Clay ❑ Ie ---------------------------- Hardpan ❑ Adobe Fill Material -- l Yes,type buildings, etc. must be placed on reverse side.) (Plot plan, showing size of lot, ' location of system in relation to wells, i NEW INSTALLATION: (No sept tank or seepage pit permitted if public sewer is available within 200 feet) { Liquid Depth -------------------------- PACKAGE TREATMENT [ ] SEPTIC TANK ] Size------------- = - q p I - Material-------------- ------- No. Compartments --------------------- Capacity -------------------- Type --- ------ ------ - i ell ------------------------------------ Distance to nearest: W Foundation ---------------------- Prop. Line ------------- -------• LEACHING LINE [ ] No. of Lines ------- Length of each line Total Length Depth Filter Material ------------------------ -------------•..... 'D' Box------------- Type Filter Material -------------------- p ---- Foundation ------------------------ Property Line. ------------------ Distance to nearest: Weil -_-- __---.-_---- - No i❑ SEEPAGE_ L 1 p I Diameter -------- ------ Number " Rock Filled Yes ❑ Water Table Depth _- -- ---------------- Size ------------•------------ ------ ----------------- Prop Line --------------r -------- - Foundation Distance to nearest: Well --------------------- ------------- - REPAIR/ADDITION(Prev. Sanitation Permit -------------------------------------------- Date -------------------•--------- Septic Tank (Specify Requirements) ------------------------------------------------------------------ ------------------ , _ �i ----------------------------- Disposal --------------------------- Disposal Field (Specify Requirements) ----41 - -------- ------------------------------------------------------------------------ --- --- -------------------�---------------------------------- --------------------------------------- -------- ------ --- {Draw existing and required addition on reverse si e ork will be o h Son Joaqu I hereby certify that I have prepared this application and that the.San Joaquin LocalHealth D strridctnt Homeowner or licen County Ordinances, State Laws, and Rules and Regulations sed agents signature certifies the following: ` erson in such manner "I certify that in the performance of the work for which this permit is issued, I shall not employ any�p� I as to become subject to Workman's Compensation laws of California." --®rthan ------------------------------------------- Owner ;Tit e ------- ------------------------------------------- By ---- -- (I - owner] , FOR .DEPARTMENT USE ONLY ------------------------------------------- ----- ------ ------- ------- --. DATE --��1��-- ---------------------- APPLICATION ---- ----------------APPLICATION ACCEPTED BY`- ---- - -- - DATE ------------------------ --------------------------------- SUILDING PERMIT ISSUED --4-+---- ------- ---------------------------- ------------------------------- ADDITIONAL COMMENTS ---------- ------ _`---tu- - ---- ---- -.. -- --- - --- ------------------------------------ -----------:.; SAN JOAQUIN LOCAL HEALTH DISTRICT F H 9 1-'68 Rev. 5M