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) FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �s_ 7 (Complete in Triplicate) Permit No. ..:.................. ......................................................... �� 's' This Permit Expires i Year From Date Issued Date Issued ..h...._....... 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 Or ' once No. 544 and existing Rules and Regulations: JOB ADDRESS/L , .`Z_G. v ......... ----- .......•-....---.CENSUS 'TRACT Owner's Name .. .............. f:. one ........ ............... -•--......... Address ..._..... ..7�1..--. ..... ........ .... City . .. Contractor's Name . .. .. -t =.......License #� _ Pho e Installation will serve: pause❑ Commercial ❑Trailer Court 0 Reside Ar ment,Ho Motel ❑Other Number of living units:_::....{____ Number of bedrooms.^.._.Garbage Grinder ----------- Lot Size ...�&....�. x�?-- Water Supply: Public System and name .......-........................-----'---...---........................._....................................Private Character of sol) to a depth of 3 feet: Sand❑ Ht❑ Clay ❑ Peat❑ Sandy loam fl Clay Loam ❑ Hardpan Adobe❑ Fill Material ..... ...... If yes,type ._......................... (Plot plan, showing size of lot, location ofsystem 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,) , 1 PACKAGE TREATMENT [ ] SEPTIC TANK Q ] Size................................................ Liquid Depth _-_------_------------ ' S CapacityType . Material...................... No. Compartments S Distance to nearest: Well ....................................Foundation ...................... Prop. Line _.-__-------------.o LEACHING LINE [ J No. of Lines .......-------------..... Length of each line,....... .........:.......... Total Length .................:......... � D' Box Type Filter Material ....Depth Filter Material ............... Distance to nearest: Well ........................ Foundation ........................ Property Line __:................. ___. i SEEPAGE PIT [ ) Depth -------------------- Diameter ................ Number ............................ Rock. Filled Yes ❑ No i Water Table Depth ..................Rock Size Distance to nearest: Well --••--.•--.----.•-------------------_-Foundation .................... Prop. Line ...................... i REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .-•.--•.---------_-------__.---•1 SepticTank (Specify Requirements) -------------------_.._..._.............................................................................----•--•------------------..__... Disposal Field (Specify Requirem-•e�tnts) ..._..... ...... . ...... . ... ..---�`. ----....----.....----...---------------------•-----•--.._..;.r;-._............. mss' -� - � .... ..... .......�-- _ . .............:_...--------- (Draw existing and required addition on reverse side) 1 hereby certify that I 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 tho-Sari joat uin Lbcal Hedith District. Home owner or i1cen- sed agents signature certifies the following:. k- "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner I as to become subject to Workman's Compen ation laws of California." Signed ........... .:......... .... ........ . ..:...... :......_.........:......_._ Owner By ............. ................ . ..._.._ ............ Title ._._...._................................._.............._._..__........ r (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...I, ......... ............. .................I............• DATE ........-- BUILDING PERMIT ISSUED ........................................................:. .DATE ADDITIONAL COMMENTS ------------------•--------------------•--_. .......................•.............. .............................................................................. ..................................................---......n• -• -•-----•••--•-- •-•---....-••..............------------------•---------------------.----------.------------•- -----------------✓._...... = .................•--......---•----------••••••--._.:._...:.n...j. ..r- ......... Final Inspection by: ...:._./�� -� L,� 1�- --.... Date ................ ............ SAN JOAQUIN LOCAL HEALTH DISTRICT 13 24 , •moo n-.. c.. 7/72 3 .K �