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rum VNICE USE: ' APPLICATION FOR SANITATION PERMIT ------------------' a .................... 4 " (COMPlete In Triplicate! Permit No. -...-.. I -----;-•.....................•---•-.....----••-- 4 ------- ..---......r • . This Permit Expires 3 Year From Date Issued Date Issued , Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work herein described. This application Is made In compliance with County Ordinance No. 5:49 and existing Rules and Regulations, JOB ADDRESSAOCATIO -"'�,1 _____•- , }.- .-.........CENSUS TRACT ............. Owner's Name .,. ... ..--•- - d- -- -- ••---------------------------- Ph .. ... Address ........... 1.1j.1\351 city one :.................. --..---•----------------------- -•------•----- -- Contractor's Name ----- License # ,._- ---------•----------- __.-.._-- - Phone ........................... Installation will serve: Residence VApartment House'[] Commercial E]Traller Court 0 t I Motel ❑Other --------- Number -------Number of living units:--- -- Number of bedrooms __ e O W.X �-....Garbage Grinder -..-.-__...- Lot Size .-- --__- . Water Supply: Public System and name ___----------------------------------------------------- ----------------------•------. . ._.._ . .. - -••-----Private Character,of soil to a depth of 3 feet: Sand[] Sift.[) Clay ❑ Peat❑ Sandy Loam IV Clay Loam 0 Hardpan Q Adobe ❑ Fill Material - if yes,type (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,} PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size----------------------- Liquid Depth o Capacity -----------•-------- Type ------ ----------•.- Material No. Compartments --......� Distance to nearest: 1Ne11;.:__ "a-----_---„--------------•--Foundation ------------ ------ Prop. Line ._______- . � i LEACHING LINE ( ] No. of Lin's - -. --------- Length Length of each line _--_---_--- - ------ Total Length ` 'D' Box .-_:_... Type.Filter Material ....................Depth filter Material ....._....- .......................••----•-- Distance to nearest: Well ........................ Foundation ,.-...--.._. ..... Property Line ........................U' SEEPAGE PIT [ ] Depth Diameter Number --r.---- ------ Rock Filled Yes �] No �] Water Table Depth •------•-•-....._ ------Rock Size ...... Distance to nearest: W`e1I ----------------------------------------Foundation ._------------------. Prop. Line(: .........-_-. - REPAIR/ DDiTIQN(Prev. SanitationPermit # .......... ..... o ....... --••-•---....---•-- Date -...... ) •” s>* fc Tank (Specify Requirements) ..----...W-Co. Disposal Field (Specify Requirements) .._ � .......................... -•--------- ------•--------•-•---------•--------------- ----------------------- ................_............................................................................................ (Draw existing and required addition on reverse side) I !hereby certify that I have.prepared this application and that the work will be done In accord'ince with San Joaquin k County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Norrie 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 shaft not employ any person.in such manner t as to bec a subject t Workman's Compen tion laws of California." Signed ............. Owner By -----_---------------------- -• -- Title ----- (If other than owner] ---------- ............... FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .- •- -------- --------------•----------- ---------------- -------------- DATE .�.. '7 .-.-.. BUILDING PERMIT ISSUED --- ----- • - DATE ..........:......... . . ADDITIONAL COMMENTS ----------------- •-----------•--------------- . --•---------- ----- -••---------••--•------------••----------------•---------....---.--•----- • --------..-..----•------... ....... ----------=-----------•----.-------,--•---------•---- •--------------•-----------•................. .--_---.-- -- ---------!------- .•...................---..-.:..---...----- ---- ------ ---• -- Final Inspection by: .--- _ },� �................. Ell ---••-•---•----------------- -------------------- -------Date .--.------- ----- i �3 1�6 5M SAN JOAQUYN LOCAL HEALTH DISTRICT h 31M I