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FOR OFFICE'USE: APPLICATION FOR SANITATION PERMIT Permit No. ......... "' (Complete in Triplicate) ............ :. - Date Issued .. ......• •- This Permit Expires ii Year From Date issue Application is hereby made tthe San q cah ta9asinstall rein described. This application is,made complianceinJoaquin wi County No. 54ndexiting Rules and Regulations: f � cj .. '................................CENSUS TRACT ............ JOB ADDRESS/LOCATION .. , .Phone _,�`��-.��?:- .•�. • Owner's Name ........ &..... _ .......................... ,. (. •..... ,r ....................... City . " ..l C�..l•.--p Address _...... - �J r f f' . Contractor's Name . -` fc� �x License # 1'�r� . Phone �j� ' ... . _ r(..- Residence Apartment HouseHouse 0 Commercial ❑Traller Court �] ` Installation will serve: � i Motel ❑Other .............---------------------- ......•. _ Number of living units:--/---- Number of bedrooms . )�.—..••Garbage Grinder .` `- Lot Size ----- ---- � Water Supply: Public System and name ......................................................_......... ............. •---•-••--•- -----------------Private ❑ Character of soil to a depth of 3 feet: Sand Silt❑ -Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam D Hardpan ❑ AdobeFill Material ............ If yes,type --------------------- . _. I �.. buildings, etc. must be placed on reverse side.) (Piot plan, showing size of lot, location of. system in relation to wells, NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) f 0 ------ Liquid Depth ...- ............... Y PACKAGE TREATMENT [ SEPTIC TANK> size... o. Com !- P Y� Material. NCompartments p .... Co alit o�� - Type! I Distance to nearest: Well ._.._�. --F dr ••-•-••. Prop. Line ....... ou . - LEACHING LINE [ ] No. of Lines ..................... --- Length of each line............................ Total Length ............. ............ D' Box ------------ Type Filter Materia ....................Depth Filter Material .......................... ...._ Foundation Property Line .....................•.. Distance to nearest: Well .....---••---•-- ....... .....---••-'--•--....'-- Depth Diameter Number ........................•... Rock Filled Yes 0 No (] SEEPAGE PIT [ i p •-•---......-- - --�-�^� Water Table Depth ...._--....Rock Size ,�`,�`/S/�7`/i•�� •--.............................. Distance to nearest: Well ........................................Foundation ...._............... Prop. Line .....-___.-._---... - REPAIR/ADDITION[Prev. Sanitation Permit# ................... Date ••_1 ----•------••••-•-•• - • Septic Tank (Specify Requirements) .- - . ..... _. ! Disposal Field (Specify Requirements) .....------- •• - ................................... •••... ...................•.................... ....................... ........................... ---. --..._... (Draw existing and required addition on reverse side) application and that the work will be done in accordance with San Joaquin I hereby certify that I have prepared this app 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- permiterson in such manner "I certify that in the performance of the work for which this is issued, i shall not employ any p as to become subiect to Workman's Compensation laws of California." • Signed Owner ...... BY / - � Title --..._ (If other than owner) FOR DEPARTMENT USE ONLY s ....................... Z✓ DATE .......... ...1•Z. ..'7.. .__.....-- APPLICATION ACCEPTED :BY ------ -- ---------- ---•-•-............ .__......-•--•-...--•---...... •--....---.....--•- DATE ...---•--. l BUILDING PERMIT ISSUED ---- -----'--......-........ ... ............. ......--•--...---•---------•......:.................................-----••---......--------•---••--•----- ADDITIONAL COMMENTS ... r .........................:._:......_Y_......:....__...-••--.....----•-.............••-...-•--•.....--•-•--•-•------•••• .,._ f. .. $.t*' E Date .. .. 7 Y Final Inspection b •--• ................ ............. SAN JOAQUI LOCAL HEALTH DISTRICT 7/72 3 M . � 1 � 24 � •moo o-... +CAA -