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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. _.7_-)-_.'._7j_'49_. ` ------------ -------- 1-- ;Complete in Triplicate) ---------------- 7 ----------------- - �- Date Issued ".-----��------ " ------------- ------------------ This Permit Expires 1 Year From Date tissued -------------------------------------------- ----------------------------------- - wor th unty Ordinance No. 549 and existing Rules and Regulations: tion is hereby made to the an Joaquin LocavHealth District for a permit to construct and install the Regulations:ere; Application compliance described. This application is mads in comp J -CENSUS TRACT p----'lop '- tr JOB ADDRESS/LOCATION "- ' ---- ..mac ---- ---- ---------- -- ---- =-=------- -----------Phone -------------------•-----•----•- Owner's Name I -- ----- --------------- --------------� City - ----- --- ---- -- - - - - ---- Address ------ --------------........... -•-------- Phone ��, � ,v ,.,...��---- ---------- ---License #��- - -�`- � Contractor's Name _ irr Commercial (Trailer Court l❑ Apartment Nouse❑ •� ' Installation Will serve: Residence ❑ p _r. i Motel ❑Other ---------------------------- , .�bb� � -` Garbage Grinder -- -- Lb t Size ----- Number of living units------------- Number of bedrooms ----------- Private ❑ ------ Water Supply: Public System and name -- Clay Loam El Silt❑ Clay El ❑ Sandy Loam Character of soil to a depth of 3 feet: Sand'D type Hardpan ❑ Adobe ❑ Fill Material -_---_--__ If yes, l �taced on reverse side.) Plot plan, showing size of lot, location of system in relation to we1ls,Yb$eW �gs'a act ble Within 200 feet,) [ it permitted if public �} NEW INSTALLATION: (No septic tank or seepage p p { - Liquid Depth --------------------------- Size -------------------- C [ SEPTIC TANK'[ ] Size--------��- r` Y PACKAGE TREATMENT [:.] No. Compartments Material------------------ Ca acitY ---- Type ------------ 1 Pro Line -------------•-------- ! Distance to nearest: Well ------------- --------------------�-Foundation _�------------------ , p' , Length of each line._ - ------_1 Total Length ,._ ----- -� LEACHING LINE [ ] No. of Lines ' f 1 tDepth Filter Material """ Y-��- --------°-- '-----�'--""-""---- ! D' Box f----- Type Filter Material/ �`J° _, r v--------- - , louAdation -""-.�� -------- Property tine. _-1-• =- - Distance to nearest: Well 22o-- / Rock Filled Yes ❑ No Diameter Number ------------------- f =, . SEEP PIT [ ] Depth ------------ - Water Table Depth ------------------------------------ --•-------•Roc Size ------ -------- -- Pro Line ----------------•----- ,� - ----------Foundation --- ----- -..-�.__: p• Distance to nearest: Well -------------------------------------- ---------------------- - -- Date ------� _ ; ----------) REPAIR/ADDITION[Prev. Sanitation Permit# ------ x, .. ------------------ ----------- ---------------- ------------- t Septic Tank (Specify Requirements) -------- ------------------ - Disposal Field (Specify Requirements) - ------------------ -- - -------------- ----- ----------------------- _..__________ ------------------------------- __________ . ____.-____.__________________________ �y ____ ______________ _ _ __-___"__________________ J t ---- ------ ----------------" (Draw existing and required addition IonYreverse side) ce h San Joaquin be I hereby certify that I have prepared this application and that in~ Local°Health D strctnliometowner or I ien- County Ordinances, Slate Laws, and Rules and Regulationsof the San Joaqu sed agents signature certifies the following: ork for which this permit is issued, I shall not employ any person in such manner "I certify that in t e performance of Workma pensation laws of California." as to become s ject to t Owner Signed ------- ------ ----- --- - ------------- Title `" - -------------- ------------------- --------------------------- ---- -------------- � er t n o ner) FOR DEPARTMENT USE ONLY ................. ------- ----- -- .............. DATE __. APPLICATION ACCEPTED By - ----- --'------ -------- DATE---------- ---- ----------------------------------- BUiLDING PERMIT ISSUED ------------ ------ --- --- -----•--•-- -------"""" - ADDITIONAL COMMENTS ------------------------------------ --- -------------------------------- - ---------�------ - -Date ,:� -------------------------------------------- Final Inspection by: __ =---- - - — - SAN JOAQUIN LOCAL HEALTH DISTRICT F- H. 9 1-'68 Rev. 5M -