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E "-- FOR OFFICE- - --USE- - ---------- Permit No:: APPLICATION FOR SANITATION PERMIT �� W----^----------- -- ---- ----- - ---- --- ---- - - -- -- (Complete in Triplicate) --- ---------------------------------------------- 7-11 Y ------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued r___.... 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 Cou ty rdinance No. 549 existing Rules and Regulations: ADDRESS/LO N '_-_--_ � - -- --- CENSUS TRACT -------------- JOB ._...--•---- Owner's Name .-_. ------------------ --------------- -------Phone --------------------..----•--------- Address ---- $ C - -- ---- ------------------------------------ -- - -- - -- ------ -- ------ -- - - --- ----- ----- wl� 67 - Contractor's Name --�-- ------- ----`- --'License #/ ------ Phone ------------------------------ L Installation will serve: Residence - partment ouse f-] Commercial []Trailer Court !❑ Motel E]Other `` Crinder s ._ ! Number'of living units:-.-- ______ Number of bedrooms Garbage ------------ Lot Size ---- - -- ----------- Water -- :_--Water Supply: Public System and name = ------- Private Character of soil to a depth of 3 feet: Sand[] Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ Hardpan ❑ Adobe-E] (Fill Material ------------ If yes, type ---------------------------- Q (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side. ,Gif NEW INSTALLATION: (No-se tic tank or ee a e it ermitted,if public sewer is available within 200 feet,) P P 9 P P rr � 1 � •� � PACKAGE TREATMENT [ I SEPT C TANK' I Size _ ___ _ ___l q p _ --- Li uid De fihCapacity �__ Type �!___ Materia ------ No. Compartments / ---. Distance to- nea t: Well ----------��-- -----------------Foundation _.___./50--_------- Prop. Line ------------ N, ---________ ..1. LEACHING LINE [ ] r :No. of Lin s __ _. �-__-.__ Length of ne--- �Qa f----_ Total Length __y� _______- 'D ",Bob :_ _- Type Filter Material _-_ ___ --.Depth Filter Material --------/_ _____________-�_:ee_--.---____._ + Dista e,t nearest: Well --_-- --------- Foundation -----_ ---t--------- Property Line ____Ii______________ -dter � Number _ _ Rock Filled Yes Na .i❑ Depth ` � r �r f Water Table Depth -----------� ------------------Rock Size --�-- ------- 7 •----- 1 Distance to nearest: Well ____._-ft-n--- -----------------Foundation,'---- Q--------Prop Line ------ ------------ REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ---------------------------------- Septic _-._____-______----____________Se tic Tank (Specify Requirements) ----------------------------------------------------- ------ ----------- --------- ------------------ --------- Disposal Field (Specify'Requirements) __________ --------------------------==- '' -.--------:-------------------------------------------------------------------------------------------- -----------------------------------------_----------- - --------- ------------------------------------- --------------------- -------------------------- ------------------ ---------------------------- ----------------------------------------------------------- I (Draw existing 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 War a s- mpensation la of Iifornia." Signed ----------------------------- --- - -- --------- Owner BY -------------------------------- _Title ---------------------- (If other than- ner) i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------- DATE _ _.. y --------- BUILDING PERMIT ISSUED -----------------------------------------------------------------------------------------_--------------DATE ------------- ----------------------------.. ADDITIONALCOMMENTS ------------------ ------------------ ------------------------------------------------------------------------------------------------------•------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------ Final Inspection by: --- �a �' ----------------------------------- ----------------------------- Date -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ,