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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ��...3.� ........... Permit No. ....... (Complete in Triplicate) r` s ........................................................ Date issued ......� _.�.7. 7 This Permit Expires I 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 County Ordinance No. 544 and existing Rules and Regulations: JOB ADDRESS/LOCATION a,.. .0.xeo. ._47-... ...............�.:.r .......:CEN TR 'CEN AC Phone Owner's Name ....;,�.t'�... ;:'_ - - - � Q•�- .................................. •_ . Address .. ...................... City ._ - ...:-•-•---:_._ ..._.. •. ......... Contractor's Name .. f - � ' a��L ' License #� l . Phone . ..'�1c .:. ... Installation will serve_: Residence ❑ Apartment House 0 Commercial 0Trailer Court 0. Motel E)Other _ Number of living units:__...... Number of bedrooms .......Garbage Grinder -Alb.. Lot.Size, Water Supply: Public System and name ".........:::::::..;.__:._.:.:._.......-- ------..... -.....................-----------•----C. L....Pr " ivate ❑- Character of soil to a depth of 3 feet: Sand r] Silt[] Clay Q' Peat p Sandy-Loam ❑ . ay oam 0 Hardpan C7 Adobe ]`,Fill Material ..._ ........ If yes,type ------------------- ------- . {Plot plan, showing size of lot, locatiori of.,"system in relation--to wells, buildings, etc., must be placed on reverse Side.) t} a it permitted if public sewer is available within 204 feet,) NEW INSTALLATION. (No septic yank or seepage p p c r .. . ,. ] ' . Size......................... .. Liquid Depth .............. . PACKAGE TREATMENT SEPTIC TANK -- ........... Line ....................... Material- Capacity - No. Compartments t ---...... Distance to nearest: Well __.......•.......•..Foundation Prop. Li t A LEACHING LINE I. ] No. of Lines .............. ......... Length of each line.-------------_ Total Len th .... ......... k - .. 'D' Box ... ;Type.Filter Material ....................Depth Filter Material ..:.. ...:. ......•--.---•--.-..........-- ... Foundation _....__. P rtY Distance to nearest: Well ._ Property-Line Line .......:..... SEEPAGE PIT [ j Depth _......Diameter ............ :..Number —, :: Rock Filled ed ••Yes N° Q G Water Table Depth ..................Rock,Size . Distance to nearest: Well ..........::Fd-undcttion ....•............... Prop. Line .-----•--_----- --- . Date REPAIR/ADDITION Prev. Sanitatio� Permit# •----- -•-•---•--•-••---1'"'•'-•---•--") .... - { Septic Tank (Specify Requirements) ......................................... ------------- ..........---.....-----• ...........................- ... - Disposal Field (Specify Requirements) ........ a --�/IVI-�. 1.:` ��------ ---------------------------- ----------- -----�.�:5-. � ,�3._....._�/.�""..........I.................... ---........----- .......... f (Draw existing and required addition on reverse side) •.. - with San Joa ui i 1 n I hereby certify that I have prepared this application and that the work will be done in accordance q E County Ordinancesr State laws, and Rules and Regulations of the San Joaquin local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed .........................•.----- --••-_. _ ...... ............ --••- Owner i ...... . .. Title .. ._....................... By ...........:... (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...'� " .. Vie.._ ......................:...---- DATE .. -......._...... BUILDING PERMIT ISSUED ---DATE .:....:..::.:........ .. ---•••= • .....•...................... .•---•• --.-- ADDiTIONAI COMMENTS i. . ...........................•-----....... ......--------- --•• ----........:--- . = ......---......'..............---_._......_....----•- .................................... :; .........-----•...... �' - ..... '...._..._......__...... ._......_.... _ .. . _.................. .... 8r Y.... ... .--........ ................ ,�r Final Inspection by: Date . . i SAN JOAQUIN LOCAL' HEALTH DISTRICT I 'A 24 , o_.. XkA 7/72 3 M