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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ----------------- (Complete in Triplicate Date Issued ------------------------------- -------------------------- This Permit Expires 1 Year From Date Issue A lication is hereby made to the Sa'n Joaquin Local Health District for a permit to construct and install the work herein _ PP described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: �7 rnrn ------------- CENSUS TRACT -------------------------- J08 ADDRESS/LOCAT N as- - - --- /;1-- ` " / . "--- l €r`-�-�- -- -------- ---- -- -- --- ---=-•-- ---i----- - ------------- -----Phone r' -- �- ------------ -Owner's Name City -------------- Address - - ----- Address -�<�_fa-- -- -- Phone } ------------------------- -----.License ## -f Contractor's Name ------------ r J ! Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ❑ Reside Motel ❑Other I:---- ------------------------------- __________ _ Number of {wing units-.-.------ Number of bedrooms ---Garbage Grinder -------- --- Lot Size _ _____ ----- ._____Private Water Supply: Public System an name --------------------------------------------------------------------------- -•------------------------- --- Character of soil to a depth of 3 feet: Sand'[:] Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam El LL Fill Material ------------ if yes,type --------------------------- Hardpan ❑ Adobe ❑ ,.1.t I N, Plot Ian, showing size of lot, location of system in relation to wells: buildings, etc. must be placed on reverse side.] l P P i seepage pit permitted if public ewer is available within 200 feet,] w� NEW INSTALLATION: {No septic or Size_✓�1�-----'IV - - ----------- Liquid Depth -----i ---•-------------- PACKAGE TREATMENT { ] SEPTIC TANK [ a f Material_-_____ No. compartments Capacity f C?00-rst: TYpe `"` �' 'w _.� --•------------ Distance to neaWell ___-____-;��2--"--- ------------foundation "___ �------------ Prop. Line _ " Total Le -- .. ----•- - No. of Lines _._r' -------------- Length of each line -"- - � LEACHING LINE [ ] ' D' Box --- ----- Type Filter Material ----- - ---- Depth Filter Material -------- - ----------�-- ------.----- 1 % _-_1 -- Foundation _____/ ------ Property Line _ -- ------ -------- Distance to nearest: Weld—_��------- ---'- � SEEPAGE PIT [ Depth Diameter _--_---___-- Numbers-"-------------- Rock Filled Yes ❑.. No ] --- f Water Table Depth --------------- ---• -- = Rock Size ,. -,. . Distance to nearest:.Weil ------------------- '== Foundation -------=-,—=------- Prop. Line -------- -------- ".------•--- w-�"'.. .� Date -----------------------------------{ ] } ---- •�> ---I------------ REPAIR/ADDITION(Prev. Sanitation Permit , w.. : 1 Septic Tank {Specify Requirements) - ------- ------- ----- -------- ------ -------- ---------------- ------------------ Disposal Field (Specify -Requirements "----------------- ----•---•---------------------- ��~ - _ ' ------------------------- ------------------------------------- ------------------------ --------------------------------------------------------- ---------------------------- - k k _________ ____________________________________________-___ _ 1 . k ______________________________________ _ � � [Draw existing and required addition on reverse side) . ne in ance 1 hereby certify that I have prepared this application and lationsthat the work will be of the San Joaquin Local oHealth District. Home rtowner or h Son cen County Ordinances, State Laws, and Rules and Regu sed agents signature certifies the Following:of the work farson in such manner certify that in the performance or which this permit is issued, I shall not employ any p as to become subject to f; ner) 4s Compensation laws of California." 1 Signed ------------------- ' Owner _� --------- } �'c.� ----------------- - ------- (IfF 8y other th FOR .DEPARTMENT USE ONLY 4 APPLICATION ACCEPTED BY ------- ----------- -'� -------- --------DATE - --------- -----------• - DATE BUILDING PERMIT ISSUED --------=------------------------------------------__- -------------- -- -- ----- ------------• ADDITIONAL COMMENTS _._ ---------------------------------- ------ -------- --------- -------- -------------------------------- - -- -------------------------------------------------- . Date "Final Inspection b -- =- - " SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M