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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT q - {: Permit No. ------------------_- + s} (Complete in Triplicate) ------ 1------------ ---"-= -----="------ ... rt!fY /---T fU t 1 Dote Issued - ------------- -------------------- " This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District fo a permit to construct and install the work herein described. This application-is made in compliance with Coyanty,Ordinance No. 549 and existing Rules and Regulations- JCtB .ADDRESS/LOC ION_ _-!--- - --- - - i ---CENSUS TRACT -------------------------- ...CENSUS ---- "`, --------- ------•-- -------- - - ---Phone ------------------------------------ / _._ _>:, -_.aJh >W ------------------------------- - city df Address --_- --- -- -- - 193_IT1_Z Phone Contractor's Name --- -- ------.License # Installation will serve- Residence,. artment House❑ Commercial :❑Trailer Court `Q i I Motel ❑Other ------------- I N'S' A----9°p--®------- Number o'f living unit"s -' `_� Number of bedrooms __1-?----Garbage Grinder Lot Size _______________ Water Su{pply: Public System+and name _________..- Private ---- - ------------------------•------ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ ;Peat❑ Sandy Loam ❑ Clay Loam / } Hardpan ❑ Adobe ❑ Fill.Material _--____--- If yes, type __________________________ i �.. [Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) r NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT f I SEPTIC TANK'[ ] Size------_ � ----------------------- Liquid Depth _---.----------------.----- Capacity 12-00------- Type ��'�(�'1�'t�- Material(��C No. Compartments --_Zn...... -------- Prop. Line 0------ ---- Distance to nearest: Well ----__ -_0:_-------=------Foundationy-____._-____ '. LEA, 3 LINE [ J No. of Lines _-.----3-------------- Length of each line_---- -- - - ------------ Total Length __f- . ----------- `D' Box'`�----_—'�""Type�FClteF'Matyerial Depth Fitter Material -----/--------------------•�-----•----•- Distance to nearest: Well -�-O------_i---- Foundation _�_0--------____ Property Line ---- --------- SEEPAGE-.PIT [ J Depth ______-------------- Diameter _ --. ________ Number -------_ y Rock Filled Yes �No C] IV Water Table Depth ---------------------------------------------`---Rock Size ------��--------•----------- ` (� i _Foundatio �•____ _ Prop. Line Distance to nearest: Well ------1.0�______________________ n�,rc` ---------- - f REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------- ----------------- Date ----------------- ------------ f Septic Tank (Specify Requirements) ------------------------------------- --- Disposal Field (Specify Requirements) ------------- - ' ---`----- ------------- I ---------- -----------------"------------------------------------------------------------------ -------------------=-------------------------------------------- --- - --------------------------------- - I (Draw existing and required addition on reverse side) I hereby certify that l have prepared this application and that the work will be done}in accordance with San Joaquin I County Ordinances, State Laws, and Rules and .Regulations of the San Joaquin-Local Health District. biome owner or licen- sed agents signature certifies the following: t { e, i r t "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 --- 1/[�. - . ----------- ........ other than owner) FOR DEPARTMENT USE. ONLY ' APPLICATION ACCEPTED by - - ------- ---- -------------------------=-------------------------------- --- DATE - -/& 71f------------------ BUILDINGPERMIT ISSUED ----------------------------------------- -- ---------------------------------------DATE ------------=----------------------------- ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------- ------------------------------------ ----=- --------------------- -------------------------------------------------------------------------------------------------------------------------------------------- ------- ------------------------------------------------------ -------------- ------------------------------ -------------------------=------------------------- ------------------------------------------------------- � -------- ---- ----�----- ----- - - - Final Inspection by: _ 1 ----- ---------------- Date ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H. 9 1-'68 Rev. 5M