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FOR OFFICE'USE: ppOUCATION FOR SANITATION PERMIT , Permit Na. ' -------- ----------- ----------------------------------- (Complete in Triplicate) r' -------------------- 2 3 - ---------- -�_ Date Issued --1----------- ----- ------ ------------------------------------ ------------ This Permit Expires l Year From Date Issued t Application is hereby,made.to.ihe-San Joaquln_Local Mealth-District-fore a permit-to construct and install the work herein described. This application is made in compliance with County:Ordinance No.`549 and existing Rvles and Regulations: v �Q/ �. ---..CENSUS TRACT ----------------- ---------- JOB ADDRESS/LOCATI Nom.------- - - Owner's Name - Phone - - --------------"--•--•--- City --- - ---- --------- ---------- Address ------------ -- - i License # _ .� � � Phone �o �J Contractor's Name _.__ _. Installation will serve: Residence,]Apartment House❑ Commercial:❑Trailer Court ,❑ rx Motel ❑ Other -------------------- ---------------------- t -. ----------- Numberlof livin6,6nits:____/__.__ Number of bedrooms __ Garbage Grinder ._~"- Lofi Size -"---- ----- --- _. Private�$J Water Supply Public System and name ---------------------------------•---------------------------- - .f Character of soil to a depth of 3 feet: Sand'[] Silt❑ Clay ❑ Peat ❑T Sandy Loam-❑ Clay LoamO" 3 t Hardpan Aclobe'❑ Fill Material ___________ If yes, type l ' (Plot plan, shovSing size of lot, location of system in relation to 'well!;>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,) w; r. - Liquid Depth --------------- -----.-•--- SEPTIC TANK' ,, Size---------- -------------- - ------ q . p PACKAGE TREATMENT { ] , � . # ..,..s,a -r-—4. ---"_-- Material--------------'_'----- No. Coriipartments _______•---------.---- j # . Capacity ---------------------- Type ------------ , . I N s Distance to nearest: Well -- ---- ---------------------Foundation ----------------.------ Prop: Line --__--•----- - LEACHING LINE t' No. of Lines - ----- --------- _1 ength of each line---------------------------- Total! Length ' i "� Box'__'._'..'_,_.-- Type Filter Material ---------------- Depth Filter Materia _ q ---Pro Property Line --------•--------------- f Distance to nearest. Well ---------- ----------- ___"`. ��-Foundat.ion� ------- P tY 1-# Number fRock Filled Yes [ No !❑ I SEEPAGE PIT { Depth ---- -�-- ---- Diameter -- _ — Water Table Depth ------ - -- ---------------------------Rock Size --- - -Foundationv_�'_ _.%--- Pro Line ---- ..... -- Distance to nearest: Well a - x, P , ' - ---=---------- - Date<'"------------------------------- REPAIR ADDITIO Prev. Sanitation Permit# -------------------- -- �. • ----------- Septic Tank (Specifj,Reeq�irements) ------------- --------------------- ti ' - ------------------------------- ------------------------ Disposal.Field (Specif' Re, -uirements) ---------- t ------------------------ 11,� `^ _ ,-: ---- ----------- --------------------------------------------------------- ------------- ---------------------- --------------------- ---------------------- ------------------------------- -------------------- - -- : ---- ------------------------------------------------------ {Draw existing4anside) addition on reverse sie) hat the work will be done in accordance with San Joaquin 1 hereby certify that I have prepared;this application and t Rules and Regulations o f the. San Joaquin Local Health District. Home owner or 1'tcen- County Ordinances;,State Laws, and.sed agents signature certifies the following: - ! "1 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 Workman's Compensation laws of California." k Signed ___.____----__ Owner ----------------------------------- -- ------ F ---- - -------- - Title -------- - - --- -- (If other than owner) p �' " �'FOR DEPARTMENT USE ONLY ' DATE---------------- APPLICATION ACCEPTED BY _- - -- --- DATE ------------ BUILDING PERMIT ISSUED -------------r-'---"'.-------------------- ADDITIONALCOMMENTS --------------------- --------------------------------- --------- -------------=------------------------- --- ------------------------ ------- ------ (f--------- ----- - --------------------- =- ------------------------------- ---------------------- -------- --------------- ----- ----------------------- Dat .Fina! Inspection by ------- -------- "' SAN JOAQUIN- LOCAL HEALTH -DISTRICT ; r`u 0 1-'68 Rev. 5M