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FOR OFFICE USE: 'APPLICATION FOR SANITATION PERMIT - Permit No. . ----•---- --1�-a ------ --------------- (Complete----- -------- in Triplicate) y -------------- Date Issued ----- ------- p------------------------------------- ------- ----�p------------- ------------------- --- This Permit Expires 1 Year From Dateissued - A tion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein i described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ,I f r , ---------------------------CENSUS TRACT -------------- ----------- -- ---- JOB ADDRESS/LOCATION ._--_ - = _ --- - - ----------- -- Owner's Name .- ---Phone - z ---. City -- Address -- / �------ -f- �1�'- l 121 — Address .! License # l'� ----- Phone ---- ------------------------- Contractor's ----------- -- - -- Contractor's Name - � . �--� Installation will serve: Residence)gApartment House❑ Commercial ❑Trailer Court ❑ Other ----------------------------- r Number of living units ---- Number Motel b❑ed�-Z - rooms _---_-"-__Garbage Grinder ------------ Lot Size _ PrivatePublic S stem and name -------L - a` ` '� _-_amu.: -------------- WafterSupply: y Clay Loam Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Y ❑ Hardpan ❑ AdobeNkFill Material ------------ If yes,type ---------- ----------------- etc. must be placed on reverse side.) C 0 (Plot plan, showing size of lot, location of system in relation to wells, buildings, V NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewerisavailable within 200 feet,) Size Z/ X ------------------ Liquid Depth PACKAGE TREATMENT { ] SEPTIC TANK } f ' . � - _--- No. Compartments ------9 / Material_ Capacity ! �C� TYP i -�p----------- Prop. Line i Distance to nearest: Well ___--- ----- ----Foundation --- LEACHING LINT: [ ] No. of Lines --_--_ Length of each line_"------------------- I - Total Length :-----------• ------•----------• De th Filter Material ------------------------------•-------- 'D' Box ------------ Type Filter Material ---_--------------. - --- __-_--'Property Line --------------•---•-•--- Dista nce to nearest: We --------------------- -- Foundation --------------- Rock Filled Yes ❑ No .0 SEEPAGE PIT Depth ----- ------ Diameter ---------------- Number -------------- Water Table Depth ------------------------------------------------Rock ------------ ---------- -----------•-----------.Rock Size ------------------------ l _..---__--•- Distance to nearest: Well ----------------------------------------Foundation ------------------- P• Pro Line _-...__:_ ' -------- Date ----------•-----------------------) REPAIR/ADDITION(Prev. Sanitation Permit ---- ------------- ------------------- Septic Tank (Specify Requirements) --__--______ ---------------------- -------------- --------------------------------------------- - --------------------- Disposal Field {Specify Requirements) ----------- ---------------------------" -------------- --- - ---------- - ----------------------- - - -- - - ------------- ------ ------------------ ---------------------------------------- ---- -- - - - - ------------------------ - - (Draw existing-= and required addition on reverse side) plication and that the work will be done in accordance with San Joaquin I hereby certify that 1 have prepared this ap d Regulations of the San Joaquin Local Health District. Home owner or licen- County Ordinances, Skate Laws, and Rules an sed agents signature certifies the following: permit its issued, I shall not employ any person in such manner "I certify that in the performance of the work for which this as to bec rpe subject to Workmol Compensakion laws of California." rU `e_ Q Owner Signed -[_.�- -- ------ --- �-� -------- --- Title -------- ----- ---- ---- - -- --------------------------- By ---------------- - (If other than owner) FOR DE;:PA1tTMENT USE ONLY ---- -------- ------ -------- ------� DATE _.5P-c;U.6X--- APPLICATION ACCEPTED BY --------�h----------------------- ------- -- - ---- DATE - BUILDING PERMIT ISSUED------------ ------------------------ erl �)u e ----------t--p----4z--;---- ", -r ADDITIONAL COMMENTS / --------------- ---------------------- ---------------- ------------------ ----------------------------------------------------------------------------------------------------------------- - --- - - Date -- --i ---------------------------- --------- - - - Final Inspection by: _.__ _�___ 4 _-- - SAN JOAQUIN LOCAL HEALTH DISTRICT r W 0 1-'68 Rev. 5M