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FOR OFFICE USE: -7 v _ _ PLICATION FOR SANITATION PERMIT /- n3 Permit No. v"-- (Complete in Triplicate) ---------------------- ----------------------------------- Date Issued This Permit Expires 1 Year From Date Issued ----- . 1-1 Application is hereby made to the San Joaquin�`ocal Health D strict for ar permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC TION _""-- ' - ----------------------- CENSUS TRACT --------------------•- {�-�- ' r Owner's Name�- - --,�---Cl?..-_ �------- - --� ------- Phone Ci --------------------•------ ---_-- Address ------------------- Contractor's Name ------I- License # L � --- Phone �fa.---- 7•- Contractor's Name ------ - r %,,.f,.? Installation will serve: Residence Kpartment House, Commercial ❑Trailer Court l❑ Motel [],Other ----------------------------- - Number of living units:---- ---- Number of bedrooms ___'__.Garbage Grind Lot Size, -------------- Water Supply: Public:System and name ---�------- --------------------------------------------- ( --------------- ---------Private ❑ �' Peat Sand Loam Clay Loam :❑ Character of soil to a depth of-3 feet: Sand❑ -Silt[[ Clay ❑- D Y ❑ ..—Hardpan-(] Adobe, Fill Material ------------ If yes, type `--------------------------- 4 (Plot plan, showing size .of lot, location of system in relation to 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,) ``- ' --------- -- Liquid Depth ------ -- PACKAGE TREATMENT [ ] ;SEPTIC TANK'S ] Size_______- ________"---.- - q p iT T e : Material -k No. Compartments ----------------- k :Capacity ------ ---------=- yP _ 'Dista ce to heare'st: Well ----------------------- ------------Foundation ---------------------- Prop. Line ---------- --•--- ! LEACHING LINE [ ] No.�of.rLines __-" ------ Length of each line---------------------------- Total Length --------------- ----•- F _W -----Depth Filter Material -------------------------------------------- 'D' Box ._____.`___,.Type Filter Material ______________ I " ------ foundation Property Line ------------------------ Distance to nearest: Well ___-------------- ------- ----------- - Diameter ------ GE - SEEPAP}T [ ] Depth f Number ---------------------------- Rock Filled Yes ❑ No p a "` �v Rock SIZE -------------------------------- ".i Water Table Depth t ----Foundation --------------- Pro Line ----.------------•---- Distance to nearest: Well -------------- ---------- �""-- p' ,_ a , r- firW Al, REPAIR/ADDITION(Prev, Sanitation Permit# - "----- ate ----------------- --- --------- --------------- --- --- - i Septic Tank (Specify Requirements) _._.---we, L(.�- a; Disposal-,Field (Specify Requirements) -----=•- - ----- l Cltsl -- ------------- --------------- --------------------------------- -------------------------- --- - ----- ------------------------------------ - - _ -----------------------------------=------------------- (Draw existing and.req- - d addition on reverse side) [ hereby certify that I have prepared this application ond�lth'uR the work will be done in accordance with San Joaquin Rules-'and Regulations of`.the. San Joaquin Local Health Distri County Ordinances, State Laws, and Rulesct. Home owner or licen- sed agents signature certifies the following: ] 111 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 ---------- ---- ---------- Title -'----- ------------------------- -------------- -P - ___ _ BY (If of a than owner) -N• FOR DEPARTMENT USE ONLY ,/ DATE ----- ----- - - APPLICATION ACCEPTED BY "- - -- ---- -- ---- - - ---------------- DATE .- I - - ----------------------- ------------------ BUILDING PERMIT ISSUED ------------------------ ----- ------------- ADDITIONL COMMENTS -------------------------------------------- --------------- -------- --------------------------------------- --------- .�— 3 rr '� } -------------------- ------------- ` ------` `--------------------------------------------------------------------------- Z- ----------- X 3- ---------- ----------------------------- ------------------------------------ -------- -- --------------------------------------------- ----------------------------------- - -- - -- --- Date " _.--y/ Final Inspection by: --- - -- '"''' ,y/ j N JOAQUIN LOCAL HEALTH DISTRICT l i/ �. E. H. 9 1-'68 Rev. 5M --_