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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit o- ----------- ---•--- - --------------------------- ----- -- --- (Complete in Triplicate) Date Issued --- p -------------- _ This Permit Expires 1 Year From Date slue Application is hereby made to th San Joaquin Local Health District for a permit to construct and install the work herein Aeplicati This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations- 7 -CENSUS TRACT -------------------------- JOB -. JOB ADDRESS/LO ATION -- Phone -Q! 1 � rte' Owner's Name City � ' �t� Address ----- 1�.»S Phone - =artment License # ��`,�" - - Contractor's Name Commercial ❑Trailer Court ;❑Installation will serve: Residence House❑ Motel ❑Other ---- - ` ___Garbage Grinder ------------ Lot Size �- ---�--------------•-- Number of living units:----1------ Number of Brooms - _-Private El-cam -�-- --- ------ -------------------------------------------------------- ---- - - Water Supply: Public System and name ---- - --- -- - Peat El Sandy Loam ❑ Clay Loam ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt El Clay C] Hardpan ❑ Adobe Fill Material ------------ if Yes,type -- - -- ------------- Plot plan, showing size of loft, location of system in relation to wells, buildings, etc. must be placed on reverse side.} lic sewer is available within 200 feet,) NEW INSTALLATION: (No septic tank or seepage pit permitted if pub PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size---------------------------------- ---- ----- ------------------ ------------ - - - Liquid Depth ----------- _ t r5 �c7 . Compartments -------- ------------ d Capacity -------------------- Type ------------------ Matericil -- t -------Foundation --------------------- Prop. Line Distance to nearest: Well ----------------------------- Z _ Length of each line------ - Total Length ---�.-�--- LEACHING LINE [ ] No. of Lines --- J ''� l / e Filter Material - - --- Filter Material .--_- ----------------------- Depth D' Box 4- rJ-- TYP f 1 Proper Line. Distance to nearest: Well -'-- � Foundation .--� - o ❑ SEEPAGE PIT [ 1 Depth -- Diameter -- ----- Number Rock Filled Yes r ------------- Rock Size ` f Water Table Depth ------6- Dista ace to nearest: Well -_1Y ---------------------Foundation -1--D---------- Prop. Line -. ----•----•- €�Date -----•------------•--------- } REPAIR/ADDITION(Prev. sanitation Permit# --------------------- oe -- ,.---------------- --•--- -•- - Tank (Specify Requirements) --------------------------------------------------------- Septic �---- t Di al Field (Specify Requirements) ----------------•-- --- r - .. --------------------- ------------------- ------------------------------------------ - - (Draw existing and required addition on reverse si e ne in I hereby certify that I have prepared this application and thatoothe work will be the San Joaquin LocaloHealth District. Homeace fh Son Joaquin owner or I cen- County Ordinances, State Laws, and Rules and Regulations sed agents signature certifies the following: p y arson in such manner "1 certify tha the performance of the work for which this permit is issued, I shall not em to any p as to bac e s ject o Workman's Com ensation laws of California." I -------Owner - - --------- Signed --------------------------- Title - (if other than er) FOR .DEPARTMENT U E ONLY — DATDATE . ----------- APPLICATION ACCEPTED BY --- -- - --------- --- ---- - -- BUILDING PERMIT ISSUED ----------------------- ------------------------ ----------- -•- ---------------------------------- ADDITiONALCOMMENTS -�.-,---- ----- ------ ------- --------------------------------------- ------------ ------ ------ ----- --- -- 3 ------------------------------------------------- ------- - ----- -------------------r - ---------- ------------------------- ------ ✓ ` - - _ __ - -- - -- -- - - --- o t/ --- -- - -- ---- - --------- ---- Date - ------------------ ------------ - -------- -------- ----- -- - - ------------------------------------ Final Inspection by. ---- ----- -�. SAN JOA IN LOCAL HEALTH DISTRICT 1 , q 1-'68 Rev. 5M