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' OFFICE USE: I APPLICATION FOR SANITATION PERMIT �7� jQ yC Permit No- --- ----------------- (Complete iin Triplicate)---------=--------------- -------- `' Date IssuedThis Permit Expires 1 Year From Date Issue-------- ----------------------------------- al ealth l the work Application is hereby made is madean compliance ec with Cou Districtdinar a No. 549 and existing Rulestalnd Regulations,ein . ' k described. This application s A ----CENSUS TRACT 0--------- ---- JOB ADDRESS/LOCATION .- ------- i ` Owner's Namer- ------ ..._.. ------------- - - - - - y G -- - --- ---- ---- ------------ Address ------------------------------- ` `` - --- Phone kt_~.---- ILI Contractor's Name ----------- ____ � ------- --------License # .E�_Q_�_!/ � Installation will serve: Residence Apartment House Commercial :❑Trailer Court ❑ Motel ❑Other ----------------------•--------------------- Number of living units:____ _ Number of bedrooms .___5----Garbage Grinder _.---------- Lot Size ----------------------------- - _ •-. - r Water Supply: Public System an name -------------------------------------------------------------- ____________ ____ _ - - ----------------------------------------- -------Private 1 Character of soil to a depth of 3 feet: Sand'E] Silt❑ Clay ❑ Peat❑ Sandy Loam .E] Clay Loam ElHardpan E] Adobe Fill Material ------------ if yes,type ------------------------ z of lot location of system in relation t wells, buildings, etc. must be placed on reverse side.) {PI'ot plan, showing size _ vt NEW INSTALLATION: (No septic._tank.or seepage mitted .f public,sewer is available within 200 feet,) ; p 3 � �� �`""' Size- - -- - - ---- Liquid Depth ------- --- ---- - PACKAGE TREATME [ SEPTIC TANK € I Capac -- Type �,-w_ Material---------------------- No. Compartments -------------- ------- Ccipocit� to nearest: Well r -=- "^-- Foirnd+ation ----------------------.Prop. Line ---------- 1 :h .te r _9 . I _�-�' No. of Lines I Length of each line ----- --------- Total Length ,--------------- LEACHING LINE [ ] I�"'"�°' ------- ------ ----- r - ------ ----------De Depth Filter Materia ox.._ - - -- Type Filter Mater:iai P nce io!earest: Well -----I-------- A. mandation Property Line ---------•------ Dista � � � t Fou " -----------i_ Diameter ---------------- Number --------------------------- Rock Filled Yes ❑ No ] SEEPAGE PIT [ 'T�' Dept � ir Water Table Depth -` ' Rock Size Foundation -------------------- Prop. Line --•---------------- Distance to nearest: Well ___ `� h ---- Date --- ---- -) J / REPAIRJADDITION(Prev. Sanitation ,Permrtl �, Jal L- _ ___________________ Septic Tank (Specify Requirement's) ---- :.__ ! - _._.: " } ecif Re =: Disposal Field (Sp Y uirements q t � ------------------ ; a�, t, , aM ----------------------------------------- -------------------- ______________________ _ 4 r (�w,exrstin,� andJrequired addition on reverse si e I application and that the work will be done in accordance with San Joaquin I hereby certify that 'I have prepared' this app f County Ordinances, State Laws, and Rules and Regulations of the SaniJoaquin Local Health District. Home owner or licen- sed agents signature certifies the following: person in such manner r "I certify that in the performance of the work for which this permit is issued, pshall not employany as to become subject�to Workman's Compensation laws off, California." l `. s``�T -------- Owner --- �_. d Signed -------------------------- -- - ------ Title ----- - ------------------- ---------- ----- --- - - - (if other n owner) _ OR DEPARTMENT USE ONLY 0 DATE -� = APPLICATION ACCEPTED BY ---- ------- ---- -- ---- -------------------------- ------------ -��,_;... :��....... _ ..._..... _o...�_�. ��.°t � DATE ------ ------------------------------- BUILDING ------- ------------- ------------ BUILDING PERMIT ISSUED --------- •---------------j ----------------- ADDITIONAL COMMENTS ------------- --------- ------------ ---------------------------- ------------------------------------------ -- ------------------------ ---Q--- ----------------------------------- ---------------------- ----•------- --- _ ------ I - r Date ------------- ------ ------- ------------------ --------------------------------- Final Inspection by. ____ SAN JOAQUIIv LOCAL HEALTH DISTRICT E. H. 9 l-'68 Rev. SM.