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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT /o Q7 .1�— Permit 4 a - .. sued -1 ---------------------------------- - __- ---------------- - (Complete in Triplicate) �5�� 7 ermi `` ,� —/{gib' Date s --- -�--• � r _ ---------=------------- ------ --------- This Permit Expires 1 Year From Date Issue A Iication is hereby made to the San Joaquin Local Health District-'for a perm it''to construct and install the work herein -------------------------------------------- pP made in compliance with County Ordinance No. 549 and existing Rules and Regulations- described. This application is p J-pWf/+rrre.y vizir-- �.CENSUS -TRACT ------------- - ------ JOB ADDRESS/LOC AT ON ---- -- 1201`-- - -- -�--- - -- --�----��- -�P��-- _ I _ -------------------------------------I '=----- ---- ---- ---=----- ------- -------Pone ------ ---:------------•-------•--- Owner's Name -- ` �� -_ � p � -- . - . -- d / f ----- A�/ -------------------- CitY Address -; - ---�-- % ' � License - _ Phon� ` Contractor's Name ' installation will serve: Residence E] Apartment House'❑ Commercial ❑Trailer Court 0 t Motel F Other _ ------ t Garbage Grinder _--_------- Lot Size ------ ------- --------------- Number of living units:------ --- Number of bedrooms --_-_-_.__ private ❑ Wafter Supply: Public System and name --__-_-'------------------ -- -- -- Character of soil to a depth of 3 feet: Sand 1K Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ y e ---------------------------- Hardpan ❑ Adobe E] Fill Material ------------ I es, type (Plot plan, showing size of lot, location of system in relation tcr wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Size- ----i b--7R�-Q------------- Liquid Depth PACKAGE TREATMENT '[ ] SEPTIC TANK'[ ] �- (�r No. Compartments Capacity I�-Q----- Type �---- -----� Material - � . Pro Line . - � Distance to nearest: Well ..--_--- Foundation _f d p. t3 o - LEACHING LINE ( I No. of Lines -----�-------------- Length of each line-___��-.-------------- Total Length ;1 ------------------- i — De th Filter Material --------------------------- ------ ;-- 'D' Box -_-___ ---- Type Filter Material -��--------- p - � Property Line ------------------•---_- [ Distance to nearest: We ------------ ------ ---- Foundation --------------- p Depth Diameter -_------------- Number _ _--------- Rock Filled Yes ❑ No 1❑ SEEPAGE PIT [ ] p -------------------- - -'� -Rock Size -----------------------• - Water Table Depth ---------------- -------------------- k ---.._Foundation ---------•---------- Prop. Line _.._.-------•-....... Distance to nearest: Well ------------------ ----------•-- Date ---------- =----------- ) REPAIR/ADDITION(Prev. Sanitation Permit# ----- --------------------Septic Tank (Specify Requirements) ------------------------------------------ -------------------------------- - Disposai Field (Specify Requirements -------------------------- ----------------- ----------------------------------------------- F - ------------ ---------------- -- -- ------ ----- ----------------- ----=---------------------------------------------------- ---------------- - ---- (Draw existing and required addition on reverse si e I hereby certify that 1 have prepared this application and that the work will be done in" ccordance with San Joaquin nd Rules and Regulations-ons of the San Joaquin Local Health �ttrIli,`ct• Home owner or licen- County Ordinances, State Laws, a 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, 1 shall -not employ any p as to become subject to Wo man's Compensaionrlaws of California." Signed -------------------------------------- Owner ------------- Title ----------- -- ---- -------- ------- i ----------------- By (if other than own r) FOR DEPARTMENT USE ONLY - ------------- ------- -------- ------------ DATE _��.-��- -�------------------- APPLICATION ACCEPTED BY - ------ r. �------.�--------------------------------------------------------- ------ - DATE -. --------------- ------------------- -- ---------------------------------- BUILDING PERMIT ISSUED ----------------------- -------- ------------------ ----- - ADDITIONAL COMMENTS ------------- ------ -------------------------------- ------------------ " ------------- Final Inspection by- ---------------- - x_ SAN JOAQUIN LOCAL HEALTH DISTRICT { . ., , 'A.Q oo.. X;1u