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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT •� ff�,3�� Permit No. .��.�'��"�� - ----------------- -- -------- -"--- (Complete in Triplicate) ---- Date Issued -��-SJ i This Permit Expires 'I Year From Date Issue 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 Ordinance No. 5 9 and existing Rules and Regulations: CENSUS TRAC ------------ 2 .Z-3- JOB ADDRESS/COCAS N ..-_ - - -. �- 2 ------------- Phone ------------- Owner's Name .- Ci ------------------------------------------------ " Address ------------------ ___"------ - `� Phone � " Contractor's Namt ,ZL -License _j. w _ - ... l stollation will serve: '•_- ResidenceXApartment House°�'Corrimercial ❑Trailer'Courf"i❑""" Motel ❑Other t Number of living units:_-__-"--- Number of bedrooms __-„Garbo_ a Grinder --------- Lot Size `" Y- ---- ------------ --------- Private Water Supply: Public System and name -------------------------------------------------------- _...__.._------_""_-- - : - - " t Peat-[_] Sandy Loam.. ,....Clay Loam Character of soil to a depth of 3 feet: Sand Silt❑ i Clay ❑ t J = Hardpan ❑ Adobe.l] Fill Material ---:---------If yes,type -i- ------;.: :. ` win size of lot, location of system in relation to wells,tbuildings, etc. must be placed on reverse side.)" (Plot plan, showing i NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer available within 200,feet,) I .. Liquid Depth SEPTIC TANK Size---- --------------- PACKAGE TREATMENT [ ) /1 9 t Capacity "#,2-O-- "----" Type Material"- No. Compartments .-" =--.•-----•••-- . . ce I� Prop. Line ---------- ---------- 'Dista ' . --- � I 1 J -- -------- ----------Foundation ------- --- -- ; Distance to nearest: Wel!� `-"".-- � �7 .k I o • ------ n . Len th of each line-_. Total Length __. . __ LEACHING LINE j� ?.No. of Lines __. �+..�----------- g �- rr ','D' Box ------ ---- Type Filter Material'-- ------•--=--- - 'Depth Filter Material -"-".�h :-�---•----•-----------•-----•- � t -- Foundation -.------ 0---=--- PropertyLine --------- ------- j (Distance to nearest: Well - D--�� - No . De th - Dia eter - -Number, Rock Filled . Yes Cl SEEPAGE PIT P ^ ; " Water Table•Depth ------------------=--------Rock Size - •- - -. - J ---Foundation - -"--A--------- Prop. Line --------------------- { Distance to nearest: Well .... --" - �-- } Date -------------- -------------------1 ., _ _�-----7--7--77- -77 REPAIRfADDITION(Prev.-Sanitation, ------------- ---� ----- Septic Tank (Specify Requirements ---------------------- - -------------1 "-------------.-..-.--.. . /F Disposal Field (Specify Requirements) ------------ ---------------------------------------------- ` -------------------------------------- ----- ---•�- ' ----------------------- ' I 7 ------------------------------------------------------------ t ----------------------------------- (Draw existing and required addition on reverse side) { I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinancesr State Laws, and Rules and Regulations of the San Joaquin-,Lo cal 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, 1 shall not employ any person in such manner ` as to become subject to orkman's Compens hon laws of California. Signed - -- -- T rn By ------------- -------- -hon--- ner--------------- "T ' Title _.� = (If other than owner) FM DEPARTMENT USE ONLY 001 aDATE. . . APPLICATION ACCEPTED BY ..- ----- ------- -- ------------- -- BUILDING PERMIT ISSUED ---------- - -- ------------------------ - ADDITIONAL COMMENTS --------------------------------------------------------------------------------------------- ------------- --- ----- ------------------------------------- ADDITIONAL ------ ---- - - -- -------- -------------------------- ---------- ---------------------------------------------------------- ------7- ----------------------- ------------------- --------- - - - --------- ----------------------- ------ - ------ ---- -- -------- ------ ---- -------- ---------------- -- - ---- --- - � _ __ ---------------------------- ate - ----- -- Final Inspection by- ------ ----- SAN JOAQUIN LOC L HEALTH DISTRICT E. H. 9 1-'6B Rev. 5M.