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A` FOR oFF c�,USE: APPLICATION FOR SANITATION PERMIT P ' Permit No: --""----•- - -- - a- (Complete in Triplicate) /� _" Date Issued �r ----- ----------- This Permit Expires 1 Year From Date Issued ZX ,` it to construct and insal te work herein Application is hereby made to the San Irian ec wiHh Couealth MytOrrict for d non a Nom549 d existing Rulestalnd hRegulations.. described. This application is mad camp ' t - CENSUS TRACT -------------------------- JOB ADDRESS/LOCATION . � " •� one ------------------ 6, '" ' Owner's Name ." �=%�-- ------ -------- --------------------------- ----- t city .- ------------------------ ----- -- �'Address --- .l_ ��`--------------- Contractor's ---- -----= - -Ar�'f - ! ' -------------------------- _"__.License #`4gWA -- Phone " Contractor shame _-"" -- -- - -�-=� -" Installation will serve: Residence partment House❑ Commercial ❑Trailer Court ❑ I Motel ❑Other F r-- �- Number of living units----/--"" Number of be _-�-.---Garbage Grinder - � Lot Size .64,7_,'.<-�- - -�-- ----------� Private ❑ Water Supply: Public System and name __,e-4aifi------- Character -----Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑., Sandy Loam ❑ Clay Loam ❑ Yes, e --------------------------- must be ❑ Adobe '[�i11 Material .__-"___"___ if es, typ x x ' buildings, etc. must be placed on reverse side.) (Plot plan, showing size of lot, location of system in relation to wells, t NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) t PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------ ------------ Liquid Depth -------------------------- Capacity ------------------- Type ------------ -------- Distance to nearest: Well "__"__-"___ ---------------Material- ------ -------- ---- No. Compartments ----------------•----- =-,3 Foundation ---------------------- Prop. Line --------- - LEACHING LINE [ ] No, of Lines ------------------- ---- Length of each ,line-.-_----------------- ------ Total Length ------------------•--------- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ------------------------------------------- --------------- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. -------- SEEPAGE PIT L l Depth __. ----- Diameter ---------------- Number ---------------------------- Rock Filled Yes 0 No ,0 Water Table Depth --- ---------------Size -" - Distance to nearest: Well "---""--------------- ------Foundation -------------- ---- Prop. Line ' � ------------------------------------ Date -------------------------------- -) REPAIR/ADDITION(Prev. Sanitation Permit# �r------------------------- if-----— --------•-- Septic Tank (Specify Requirennents) ----------------- - -- ----- - -------------------------------- ---- _ Disposal Field (Specify Requirements) -_- 7` - X' ------------------------- �' ---------------/--------------- ---------------------- ------------------------ ------------------------ ----------------------------------------------------- _ (Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,)State Laws, and Rules and Regulations of the San Joaquin Local Health District. Dome owner or licen- i, sed agents signature certifies the following: person in such manner "I certify that in the performance of the work for which this permit is issued, I shall not employ any as to become subject to Workman's Compensation laws of California." + .. - Signed --------------------- --- ------------------------------ Owner Title ".- , 'e 44� (lf of han owner] FOR DEPARTMENT USE ONLY t DATE z --' APPLICATION ACCEPTED BY ---r---------- --- -DATE ---- -- ------------------ ------- -------- BUILDING PERMIT ISSUED --------------------------- ---------- ------------------------------- ? _}- - ---------- ADDITIONAL COMMENTS `--- w ------------------------- - ----- -------------------------- -- a ------------ ------------------------------------------------------------ - --- Date �� --------------------------------------------------------- ---- --- --- --- ----------------------------------------------- --- - -- Final Inspection by- --------------- - - '- - - • SAN JOAQUIN LOCAL HEALTH DISTRICT , > w E. H. 9 1-'68 Rev. 5M