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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .��.... ... ...:......... ................:............ Permit No. .. � (Complete in Triplicate) `fThis Permit Expires-1 Year From Daty Issued Date Issued . �O ....................................:...... - Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the,WOrkyheroin described. This:application is made in compliance with County Ordinance No. 549 and existing Rules and Requlationss h // SU JOB ADDRESS/LOCATION ... .. _........... ....w..l. � '. CENSUS TRACT .... Owners Name ..- .. ...-. Phone r� Address v . .....CLiictyen-s-.e s7..'3 .. �1).. jF Phone ss+ti` Contractor's Name . Dict�a�--• Installation will serve: Residence Q Apartment House❑ Commercial ❑Trailer Court Motel E]Other............... fi,x` x n} Number of living units:... ....I.. Number of bedrooms ... ..-.Garbage Grinder ............ Lot Size ...r3- Water Supply: Public System and name ......... PrtvOte Character of soi!to a depth of 3 feet: Sand j] Silt Q Clay E] Peat E] Sandy Loam ❑ Clay Loam i r Hardpan E] Adobe E] Fill Material ......... ..If yes,type 1.(Plot plan, showing size of lot, location of system ,n relation to.wells, buildings, etc. must be piared'on,reverseide.) ; t, NEW INSTALLA710N: (No septic tank or seepage p;+ permitted if public sewer is available within 200 feet,) a PACKAGE TREAiMCNT [ ] SEPTIC TANK ] Size..... ...----------------------- Liquid Depth `- >� No. Comoartments 5 Capacity ... Type .... Maternal . ........- 4' ' Distance to neared: Well ............. ...........--F Prop. Line r r� =y len th of each line.-. . .. ..----.- Total Length ' 9 ° yLEACHING LINE [ ] No. of Lines ........... 3 w nr D' Box .-.._....._ Type Filter Material ..... .. ........ Depth Filter Material ri r` Distance to nearest: Well ........................ Foundation ...... ..-..-- Property.L ne :✓ Lq xa Rack Filled Yes Nur,ae SEEPAGE PIT [ j Depth Diameter •-- - . Water Table Depth .. ....................Rock Size y Prop. Line 1 Foundation ............... ..... p ,: .. Distance to nearest: Well ...............:..................... �.y REPAIIE/ADDITION(Prey. Sanitation Permit# . -----:... Dote ... F SS Septic Tank (Specify Requirements) ......... ...... — . -.-.......................... . . ............... O c - ............. ... 1� Disposal Field (Specify Requirements) �• �G U G M .. ..................... - r ------------------------------- --- --- --- s W, .._ - ......- (Draw existing and required addition on reverse side) one in accordance wi 1 hereby certify that I have prepared this application and that the work will be dwne Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Jaequin local Health Disr or Itcen hid. Homs owner sed agents signature certifies the following: b "I certify that in the performance of the work for which this permit is issued, I shall not employ any Pers : .n such manner as to become subject to Workman's Compensation laws of California." Si ned . ... ..... Owner to �x 9 7it!e ...:.. .... - - D .ewe- - (If other than owner) FOR DEPARTMENT USE ONLY �� -- DATE . a'.. APPLICATION ACCEPTED BY- . c�C.Cr..LZ...............�... ....DATE ........ --------------------- st; € ---------- BUILDING PERMIT ISSUED...................................................................... tJ .."i:r..� n- ................... ( ....- ...................................... ..........COMMENTS... _ . ........................ ........... ""•--•-----•--..-... ..... .......... -•----.---------- -..... ........................... . .___..-. ............. ... -. _-.--...... .. .. Date Final inspection by '. C11Q.•-•-•- SAN JOAQUIN LOCAL HEALTH DISTRICT s E.H. 9 1-'68 Rev. 5M s. I � �. .- .._...___:��.�'��"..za.x`g�`.'by`'Q�w.`'ka•,`",�,�'�i�'9i�it�s��A�".�,��'v��;f.��" ��?�t� ..�%i