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FOR OFFICE USE: _ APPLICATION FOR SANITATION PERMIT Permit No. -. ----------------------------------------------------------- --------------------- ---------------- - (Complete in Triplicate) ----- ----------- i ' Date Issued -._ lD --------- ! This Permit(Expires ] Year From bate ssue �S•t ------------- Application is hereby made to the,San Joaquin Local Health District for a permit to construct and install the work herein ----------- - - pp a application is made i .complllance. ith County Ordinance No. 5.49 and existing Rules and Regulations: described. This pp m = - -- x V j. r. �{. SUS TRACT 1G E 7T Z t - ll JOB ADDRESS/LOCATION '� - - - --------Phone. 7 .. Owner's Name ------ City .�4_ --------------------------- - - ------------------- Address - ' ' # _ Phone ------------------------------ License P Contractor's Name -- ---- - :i --- - ------ ----- ------ ----- ---------- -- - installation will serve: Residence ❑Apartment House-F] Ca mercial ❑Trailer Court .❑ ' Motel Q Other .�- �=�- ----- ( 11 - Number of living units:_-------- -- Number of bedrooms -____- Garbage Grinder --__-------- Lot SizeA164 - -- -- -----_-- private ------------------------------------------------------ Water -------------•----- --------------------- Water Supply: Public System andname ---------------- ❑ Clay Loam ❑ i Silt❑ Clay ❑ Peat❑ Sandy Loam Character of soil to a depth of 3 feet: Sand'Q Y --_ reverse side.)�� y Hardpan []�.. Ac[obe []_ Fill Materkal-:---- ,-- If.y s yp a , iplot plan, showing size of lot, 'location of system in relation to wells, buildings, etc. must be placed on Pt," seepage pit permitted if public sewer is available within 200 feet,) NEW INSTALLATION: (No sec tank or Liquid Depth �---------------- SEPTIC TANK'S Size-_:�_u-k-•-�- - -------------- q p PACKAGE TREATMENT L ] No. Compartments ------------------ Capacity !n1 n ------- Type - �/�'---- Material--X111 F` r s, Distance to nearest: Well ____ �'---- -- ---- --- -----Foundation 1- --- �--------- Prop. Line ------ A__ LEACHING LINE [ ] No. of Lines ------------------------ Length of each line-----�- --- Total Length -----•-- D' Sox .- -- Type Filter Material 5-�&-------- -Depth Filter Material ---�-- r I r Line :"!----- --------•----- Distance to nearest: Wsll -_�-�-�---�------- Foundation -_I--�'--�------- -- Property No Q SEEPAGE PIT [ ] p E --- - Diameter Number -- - ----------------- Rock Filled Yes Water 'Table De th _.%�---- ---------------------Rock Size ----t- r------ Distance to nearest: Well -_ -�--_ --- - Foundation ---D - Prop. Line a_.------ IDate ------------------- --------------1 REPAIR/ADDITION(Prev. Sanitation Permit ------ Septic Tank (Specify Requirements) ------------- ---__-_-_------ Disposal Field (Specify Requirements) ----------------------------------------- ----------- ------------------------------------------------- ------------------------ - - ,. ;.,__ :------ ------------------------------------------------------ --_---- --------------------- -------------------•------------------ ---------------- - --•- {Draw existing and required addition on reverse sirk will be e oin accordance 't I hereby certify that l have prepared this application d that the Son Joaquin Loca# Flealth District. Ho eowner or I cen- County Ordinances, State Laws, and Rules and Regulations sed agents signature certifies the following: shall not employ any person in such manner "I. certify that in the performance of the work for which this permit is issued, I as to become subject t5oZrk �s C m tion laws of California." Owner Signed - _________ ---- ------ - - - - -------- -- Title --- -------------- ------- ------ ------- ------- - ------------------ - (if other than owner) FOR DEPARTMENT US- ONLY ' ----------------------------- DATE Q"- � - -------------- APPLICATION ACCEPTED BY --_ DATE -----------•------------------------------- -------- --------- - - BUILDING PERMIT ISSUED ------------------------------------- --------------- ADDITIONAL COMMENTS .-.--------------7-------------------------- _ _ --------------------- _ ----- - --------•- Y - -- --------- ---------------- ----- ----- = ------------ --- ------ ------ - -- - -- - ---- -------------------------------- ----- -------- Dater--------- Final Inspection by 4 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M