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FOR OFFICE USE: ApPLICATIOWFOR SANITATION PERMIT Permit No. �---- -------"--"-- (Complete in Triplicate) Ff i7" Date issued ---_- -------- This Permit Expires l Year From Date issued --------------------- -- ------- ------- Application is hereby made to the son Joaquin Local Health District Ordinance for cl Nom549 and existing Rules it to construct and tand Regulations- described, egulat ons- described. This application is made in complianceS� r� - CENSUS TRACT ---- - ----------------- JOB ADDRESS/LOCATION .-�_ K-S j------"-?-'- ` . . -- . ---- Phone' " -----=-•--- ----- - W • f?l - y - ------------------------- Owner's Name ------ ------ ----- ------ ---- ------ ------------- ----- --- Address 1-71-4-5-1------- _ACL------------ ---- Cit -�- --------- ------- ------ ----------------------------•-- �J �---- r`". 'de` License # �v_ Phone ------------------- -- - Contractor's Name -_-_Cn Installation will serve: Residence Q6 Apartment House Commercial ❑Trailer Court ;[I Motel ❑Other ------------------------------------------- Lot Size _.- - ---•-----•-""- Garbage Grinder ----------__ -------------------- Number of living units:___-__� Number of bedrooms _"_ -_______ _-----_private ----------------------------------------- -----------•---- - Water Supply: Public System and name ------------------------------------ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan [Xi Adobe ❑ Fill Material ------------ If yes,typ Y it i location of system in relation to wells, buildings, etc. must be placed on reverse side.] (Plot plan, showing size of lot, itted if public sewer is available within 200 feet,) NEW INSTALLATION: (No septic tank or seepage pit perm Size -------- Liquid Depth -------------- ------.----- c SEPTIC TANK:[ ] "-------- PACKAGE TREATMENT [ ] No. Compartments Ca acit - Type -------------------- Material-------------------- Distance to nearest: Well _----- - --__ Foundation ---------------------- Prop. Line ---------------------- J - - ------- - I 'Total Length ----------------------•----- X ` LEACHING LINE [ ] No. of Lines - Length of each line- g ---------------- ------ Type Filter Material --------------------Depth Filter Material ----------------- 'D' Box -----__--- - ` Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ---------------------•-- Z --_ ---- Diameter -" Number --- -------- --------------- Rock Filled Yes No SEEPAGE PIT [ ] Depth -------------- - - Water Table Depth -------------------------------------------- 'S ----Rock Size -- =---=-!-------------------- .e' ------ ------------ -------------------------------------------- .e' -----•---•----•- Distance to nearest: Well ----_---_`-----------------------------Foundation ------------ ------ Prop REPAIR/ADDITION(Prev. Sanitation Permit# -------•----------------- ------ ------- - Date ---- ------------ - 1 Septic Tank (Specify Requirements) -------------------------------------------------- -- ,--------------------------- Disposal Field (Specify Requirements) -" -- -'-� ----------- F - -� - -" ,�x ------------------------ ------ - - -------- ---------------- ----- ----- - (Draw exi-sting and required addition on reverse and h San Joaquin I hereby certify that I have prepared this aped'Reg t ulationsof the San Joaquin Local Health Distrhat the work will be done in ict. ce t Homeowner or I cn e County Ordinances, State Laws, and Rules an g sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." � Owner x Signed -- ------ -------------------- ---------------- -------------- ------------- _ _ •sa-ate Title ----------- ----------- P --- (if other than owner) ' FOR`DEPARTMENT USE ONLY APPLICATION ACCEPTED BY..-- -- --- - - - ---- ------------------------------- ------------------------- DATE ------------------- DATE --'3-------------DAT --- ------- ------ - BUILDING PERMIT ISSUED ------------------------- ADDITIONAL COMMENTS ------------------------ - ---------------------------- ------------- --------------� - ---------------------------------------------------- ----------------------------------- - --- ------ ------------- - - Date V -- - - ----------------------------------------- Final Inspection by: -- - ---_ -- - - - SAN JOAQUIN LOCAL HEALTH DISTRICT V u 0 1_'68 Rev. 5M.