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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. -- ( -= `� 7°------------14- --------- ----- - {Complete in Triplicate) � - ----------------------- Date Issued -----=----------- --------------- ------ - ----- This Permit Expires 1 Year From Date issued ------ i. Application is hereby made to the Sacom complianceLocal with CounDistrict Ordnance permit and existing Rulesinstall nd Regulations. described. This application is made in- p - I o ------CENSUS TRACT - ' JOB ADDRESS/LOCATI -Phone=--?7�---74------- -�'. r ----------------------------- Owners' Name --------- ------ ' � ----��,��,�'-- � ----.-. - - -- --- ------------------------------------------------ Address ----- ------ ------- -- - ---�..__ Address -- _- ---- 1 _ /__-- Phone ____-.License #� �--' Contractor's Name -`��-�p -- �-�----"--�------- --- - Installation will serve: ResidenceXApartment House❑ Commercial ❑Trailer Court -[I ' r - .,r Motel F1 Other ----- ------- --------------- - --- --- - Number of living units:_-------- Number of bedrooms - -----Garbage Grinder __ --- Lot Size Tom' J Private ❑ Water Supply: Public System and ndhe� Character of soil to a depth of 3 feet: Sand'[] Silt❑ Clay ❑ Peat F] Sandy Loam ❑ Clay Loam ;❑ Hardpan ❑ AdobeFill Material ------------ If Yes,type ---------------- 1 etc. must be placed on reverse side.) Iplot'plan, showing size of lot, location of system in relation to wells, buildings,s g , NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size--------------------------------- ------------ Liquid Depth ----------------------•--- I ----------------••---- I Capacity - --------------- Type -------------------- Material------------------- Na. Compartments Distance to nearest: Well ------------------------------------ ion -.- ------ prop. Line rFoundation---- ----- Total Length .—&---------------- LEACHING LINE _ [ ] ,,+,No. of Lines - - - ------------ -- Length of each line____- 'D' Box -_ Type Filter Material __XaCk -----Depth Filter Material ----/ - --- --•------------- Distance to nearest: Well __-------__-------- __-_ Foundation ---1�---------- .- Property Line. �-------------•----- j( ', Q_ Number - --------f---------------- Rock Filled Yes No 0 SEEPAGE PIT [ ] Depth _- -- -- - ---- ---_. TDiameter�� --- --------------------------------Rock Size -.a5r=°-------------- Water Table Depth __--��--- ---------- Distance fio.nearest: Well ----"7777��<------------------------Foundation -----1�--------- Prop. Line - ....... •------ REPAIR/ADDITION(Prev. Sanitation,Permrt# ------------ ------------------------------ Date --------------------------------- t_- --- --------.----- ------------------------- Septic Tank (Specify Requirements -_-------------------- -------------------------------------- ------------------------------ Disposal Field (Specify Requirements) -------------- ---------- ------- --------- ---------------------------- ------------------------------------------------- - y -------------------- ------------------------------------------ Q} d ------ ---- - ----- ----------- and required addition on reverse side) I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I 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 --------------- - ------- --- -- --------------------------- By ------ ------- - ------ B - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ` �a z . �-'tY�r DATE T 7'Z-~0----------- BUILDING PERMIT ISSUED -- -- - ---------------------- ----- -------DATE ------- ---------------- ------- ---------- ------------ + ADDITIONAL COMMENTS ------ - ------------------------------------------------------------------------- - - ---- ------------------------------------------------------------------------------------- ------------------------------------- - ------------ ------=------- e�f'b Fi inspection ------- Date ------- Final Inspection by: --- -- 1 - -- pl� Hpwy SAN JOAQUiN LOCAL HEALTH DISTRICT hcu,cdz ' -b 00--We'r F- H- 9 1-'68 Rev. 5M �'