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_r FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: :7-�-------------------------------- -------------- - (Complete in Triplicate) ------------------------------ ---------------- Date .Issued _--_ -"-Z-�---7 L This Permit Expires 1 Year From Date issued ----------------- e work I Application is hereby made to the San am 19anoe Local Coy District non a for a permit and exist i g Rules tand hRegulat Regulations: described. This application is made compliance ii�d _� - /[ CENSUS TRACT -------------------------- JOB ADDRESS/LQN -------------- ---------------- - • Phone --- ------ -------•--------•---•---- I Owner's Name --- -- -- ------------ ---- ` - _ _9 - '--- - - ----- _ / �_. city ----- ------------------------------------- - - - -- --- --- -- ----- -- - Address - ---- / -•------•--- Contractor's Name ___________ _ _ - --- --license # 1�� Phone ' installation will serve: Residence Apartment House❑ Commercial : Trailer Court ❑ I Motel ❑Other -- ---------------------------------------- Size ------ ------ ------- -- --- - - Number of living units:--_ ------ Number of bedrooms ____-__Y____Garbage Grinder --- ------ Lot I_ _--Privateit ---- --- Water Supply: Public System and name ___________________t•--- - Clay Loam Character of soil to a depth of 3 feet. Sand'❑ Sift❑ Gay E]---- Peat❑ Sandy Loam ❑ Y Hardpan ❑ Adobe.l] Fill Material .-----------I If yes,type ---------------------------- buildings, etc. must be placed on reverse side.} F {Plot plan, showing size of lot, location of system in relation to wells, y NEW if public sewer is available within 200 feet,) EW INSTALLATION: {No septic tank or seepage pit perm \ PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size-------------------------------- Liquid Depth ----------- -- Material------------- No. Compartments ----------------- Capacity - ------------------ Type ---------------- ._ Distance to nearest: Well ------------------------------------Foundation -------------------- Prop. Line ------------------•- } ---- Total Length ---------------•------------ C - Length of each line________________________ LEACHING LINE [ ] No. of Lines _______________________ 9 _.. . -- , D' Box -------- -- Type Filter Material --------------- _Depth Filter Material --------------•--------------- - } ---------- Foundation ------------- -- ----- Property Line Distance to nearest: Well ____-_-_"---- ' r I Number -___----------------------- Rock Filled Yes C] No 0 Diameter -------------- SEEPAGE PIT [ ] Depth�.-------------- --- � • TableDepth -----------------`---------------------- Rock Size ------------------------------ Water f Foundation ---- Prop Line -----•-- ------------- I1 Distance to nearest: Well ____----.'----------------------- I --- °--------------------------- Da#e ---------------------•---- -------1 f REPAIR/ADDITION(Prev. Sanitai ion Permit# ------•• = : Septic Tank (Specify Requirements} --------------------------------- Ik- ---------- --------- Disposal Field (Specify Requirements} ._- - - R� Z- S ' ----------- ---------------------------------------- --------------------------- _ -i---------------------------------------------------------------------------------------------- --------------------------------- {Draw existing and required addition On reverse Si ' I hereby certify that I have prepared this application and that,the work will be done It accordance with San Joaquin County Ordinances, State Laws, and Rules and. Regulations.of-the San Joaquin Local Health District. Nome owner or licen- F sed agents signature certifies the following: h 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." Owner Signed ------------------- ---- --� ---------------------------- (If other than owner) FOR DEPARTMENT USE ONLY _ ------------------------------------------------ ------------ DATE ---�=-�'-3=-- ------- ----------- APPLICATION ACCEPTED BY_.___:_ -- -'------------ BUILDING PERMIT ISSUED -_------------------------"----------------------------------------------------------- ----= DATE -- ------------•---- ADDITIONAL COMMENTS ---------------- -------- "-•----- ------- - ------------- -------- ------- --- -----j--- - ---------------------------- - ----- _ Date �ti--- ------------ Final Inspection b -------- ---" ------- �------"""-� ------------------------------ -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'a8 Rev. 5M