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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: . �-Q ------------------ ------------------------------------- j (Complete in Triplicate) ------------------------------- Dare Issued -- � This Permit Expires 1 Year From Date Issued l the Work Application is hereby made to the San Joaquin Locall'H1eCouth nt'stOrdinarict rna permit and existing Rules and tand ReguldtonsfeFn described. This application is made in compliance Y r ! ) Q----�----Q "-__�__�� - -- -------------------CENSUS TRACT ------;------------------- JOB ADDRESS/LOCATION .____��-- Owner's Name;LA Y-"" "" ------- ---------------------- = Phone ` f --------- Cit --- - Y -- :_ Address --------------- - -- b •' •� --� -3-- Phone ------------------------ i Name __.__ License # -.---y-7 z Installation will serve: Residence ❑ Apartment House,❑ Commercial .9railer Court • , Motel ❑Other _ ------ - � Number of living units_____________ Number of bedrooms ._--,--- Garbage Grinder -,-.-------- Lot Size - Water Supply: Public System and name --------- 4----y,-----------------------•----------------�------ - - Private ❑ Peat Sand !oam Clay Loam Character of soil to a depth of 3 feet. Sand'❑ Silt❑ Clay .❑ ❑ Hardpan ❑ -Adobe Fill Material ----------- If yes, type---------------------------- } (plot plan, showing size of lot, location of systembuildings, etc. must be placed on reverse side.) `in' relation to wells, i NEW INSTALLATION: (No septic:tank or seepage,-pit permitted if public sewer is available within 200 feet,) ? t Li uid Depth PACKAGE TREATMENT [ I SEPTIC TANK [ ] .� Size------------------------ ------ p Material No. Compartments11 Capacity -+ ------- ---- T ' e Distance `to nearest: Well ---___-___- Foundation ----------------------.Prop. Line ----------------------- p ` -------- Length of each line--------------------- Total�Length --.---.--- LEACHING LINE [ j No. of Lines -_________- I ------- - Depth Filter Material --------- ---------- -----------I Box __�.._----- Type Filter Material P ---- Property, Line. ------------------ •--. . Distance to nearest: Well -_________________ ____ Foundation _.____._____--."--- , Depth ' Diameter ---- Number ---------------------------- Rock Filled Yes ❑ No i❑ SEEPAGE PIT [ 1 P r --------- Water Table Depth --------Rock Size Distance to nearest: Well _______________________ -----------Foundations - Prop. Line ; Q I ••-------- ---------1 ! REPAIR/ADDITION(Prev. Sanitation Permit ----------------------------------- Date -------------- E - e Septic Tank (Specify Requirements) ------------------ -_.__-" _"----__ Disposal Field (Specify Requi:ements) -- "--- + ------ ----------------- -•---- ,. .- .d - ----- - ------ } = - i' ---------- ------`-------- -------- --------- -------- ---- - --------------------- r I 1 ' Draw existing and requir d addition on reverse side[ 4 I hereby;certify that I Lhave prepared this application and that the work will„be done in accordance wit., San Joaquin I County Ordinances, State Laws, and Rules and Regulations of the iSan Joaquin:Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1'shall not employ any person iir such manner as to bec subject t orkma s om ensation la of California." o wner Signed -- ----- --- -------- Title --- ------------------------------------------- r (lf other than owner) i } FOR DEPARTMENT USE ONLY 71 DATE -- ------------------ APPLICATION ACCEPTED BY ___ ------------------------------------------ ` BUILDING..PERMIT ISSUED ' _... -------- --=------ DATE = ADD1TibNALCOMMENTS ------------ ------------------------------------------------------------------------------------------------------...-- -------------- D'------------ ---------------- F -------------- FicaInspection b a A.' SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M