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FOR OFFICE USE-. FOR, OFFICE USE: APPLICATION FOR SANITATION PERMIT w Permit No. -- - ---- "-" '-"-"" (Complete in Triplicate) - ------ Date issued-Z/ -' ..............:. ---- . .. This Permit Expires 1 Year from Date Issued �Applicotion is hereby, made to..the San Jodquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance;with County Ordinance No. 5A9 and existing Rules and Regulations: A �G�... --- ............ -- ----- .CENSUS TRACT ------- JOB ADDRESS/LOCATION I Phone --... .._.- P e Owner's Name'. ........... .. � ... Cit - - .. .. . . . --..._ .......__._ . y zip.�6 Fe Address_ Ad 7 .License # f`f. 3 Ph ane. . Corltrdctor's Name_. ---- -- ----� ----- ... - ._.... _.._. p Trailer Court ❑ Installation will serve: Residence Apartment Haase Commercial ❑ r.,. Motel ❑ Other_- - Number of living units:----l.--------Number of bedrooms_.__. ..Garbage Grinder:-.-.- { Lot Size Private 'y f - Water Supply: Publ.lc System and name --- 'Loam „ J Character of.soil to a depth of 3 feet: Sand [D Silt ❑ C1ay.O. Peat [❑ Sandy Loam Cla Y te............... Hardpan El . Adobe ❑ Fill Material.. .... ;.. If yes,. yp building s, etc. must be laced pn reverse side.) (Plot plan, showing size:of lot, location of sy.stern in re erm n to tteds*If public sewer is available-within 200 feet,) /�� On NEW INSTALLATION:' (No -septic tank or �seepclg p p , 1 T PACKAGE TREATMENT„ { I__,SEPTIC TANK. Ne 1Ze -.--.-.._ . _._. Liquid Depth--.... --- ..Material.._ Compartments------., Capacity TYPe -- . . r -�`_.- _..._: �-- ��-....Foundation-•-- �i7. .�-'._-. Prop. Line- ------ ---------- Distance to nearest: Well_-. ....... ` Total Length . P4 ---- -------- LEACHING LINE No. of Lines --- 3 = ----- .Length of each line,- ----- --- - -----_.. a�terQia'�Q / Depth ttihonFilter�Ma-"t-erial. - 'D' Box -vo.Type Filter M Line.._.- ---�-Property .......... ---- ------ Distanceta nearest: Well _ k Rock Filled Yes ❑ No❑ SEEPAGE PIT ) } Depth._:. ..Diameter------- ------- ---Number---------------- f------------- i Rock Size---------- ---- - -- ------------------- ---- i Water Table Depth--------- --------------- .._...---....-. _.a ff -Prep. Line_ _ ..------------ foundation-- -------- --- ---- to nearest: Well_.._._: .-----Distance ,1� ------------ REPAIR/ADDITION (Prev. Sanitation.Permit#--------------------- ---- .. ._..Date- ---- ---- ----------- ----- --- j .--- . Septic Tank (Specify Requirements)............._.:---,�- --- - Disposal Field (Specify Requirements).: .. -------- - ------- ................ ------------. .. t 'T. --------------------------------- . g q or licensed age ty _ -- � (Draw existir, and re u'sred addition on reverse side) I hereby certify that l have Prepared this application and that the work will be done in accordance with San Joaquin Courcy Ordinances, State Laws, and Rules and Regula ons of the San.Joaquin Local Health District. Home owner signature certifies the following: any person in such manner as "I certify that in the performance of the work for which this permit is issued, I shalt not employ to become subiect to Workman's Compensation laws of California." Owner Signed.... ......... --------------- .. -- --- ------- --- � --- � _ - a - -------------- f r ( f other than owner) FOR DEPARTMENT USE ONLY " DATE - -- i APPLICATION ACCEPTED BY..-C-. ---------- ----- ------ ---- ---_._..DATE.... -- -- ----- --- ...--- . . ..-. ---- - DIVISION OF LAND NUMBER... ..... ........ . . - ._..._.._.............-.._. ----- ------------------- ------------------- - ADDITIONAL COMMENTS-------------------- .... .. .......--.- : ...- -- ----------- .-Date. ... . - S 21677 REV. 7/ 63 Final lnspecrian b w._. .`.. - � Fa 7 EH 13 24 SAN JOAQUIN LOCAl'-HEALTH DISTRICT