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N, f FOEC�E,�USEAPLICATION FOR' SANITATION PERMIT Permit No:(Complete in Triplicate) Date Issued ___, This Permit Expires 1 Year From Date Issue -. r--_ Application is hereby made to the San compliance with Coucal Health ntytOrdi arict m e permit and existing Rulestalnd Regulations..e�n described. This application is made P I _ --------- CENSUS TRACT JOB ADDRESS/LOCATION .- - ;® Phoney"--_ �- Owner's Name ------- ------------------ ------ 00 00 ---- Ci#Y -------------- ------------------------------ ------------ ------------------------------ Address - -------------- ------------ - - �_ ;p;.� 5 -J7 Contractor's Name ------------ - --- - ----------------- --------License # �: -- �---- Phone -- ------ -------- - Installation will serve: Residenceo partment House❑ Commercial:OTtailer Cour#"'❑ or Motel ❑Other ----------------------------------- I i !I i units:_._ -�_.- ber°of,bedrooms ------._Garbage Grinder Number of living Num Cot Size :___ - PrivateX Water Supply: Public System and name _---_----- --------------------------------------------------- • Y� Sand 'Loam,❑ i Clay Loam Character of sol! to a depth of 3 feet: Sand'❑ Silt ElClay ❑ Peat❑ YN y� I Hardpan ❑ Adobes` Fill Mater'sal ------------ If yes;type ____-- ----------------- --- buildings, etc. must be placed on reverse side.) (Plot plan, showing size of lot,'location of system in relafion to wells, F NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK[ I Size---------------- -------------=------>. Liquid Depth -------------------------- Compartments ' Capacity. .--- - - Type ------ ------- --- Material---------- ------- -_ No. r Distance to nearest: Well -------- ---- --------------- Four,dation Prop. Line LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length -------- Depth Filter Material -------------------------------------------- 'D' Box •____-- ---- Type Filter Material ------------------- Foundation Property Line. ------------------•----- t --------------- -------- Distance to nearest: Well ------------ ----------- No ❑ SEEPAGE PIT [ ] Depth �- - - ------- Diameter ---------------- Number ---------------------------- Rock Filled yes ❑ Water Table-Depth -------------------- --Rock Size �-. ------------------------- i t_; Foundation-._------------------- Prop. Line ---------------------- Distance to nearest: Well ---------------- ---- ----------- I -- ---- ,N- ; ^ ` 1-- ----------- Date ------------ r -------------- REPAIR/ADDITION(Prev. Sanitation . erm - --- - il'. --------- --- --------------r---- - ------ Septic Tank (Specify Requirements) _---=----------- Ate` • � #. .,• _ - - '�--L-%�-�-/fwd- 'Tr1'-j•".-'-�_t�9i`� Disposal Field {Specify Requirements) -_.-1�% - r _ l ((JJ�� t -- -----------�- ---- s --- l - ----- --- - - i (Draw existing and require addition on reverse side) ne in accordance I hereby certify that 1 have prepared this gppli Re ulationsnd that the work will be of the San Joaquin LocaloHealith District. Home'th Son owner or leen County Ordinances, State Laws; and Mules ands g j sed agents signature certifies the following: arson in such manner "I certify that in the performance of the work for which this permit is issued, I shall not employ any p as to bac su 'act to,W km Compete on laws of California." -- ------- ----------- Owner Signed ----- ---- -- ----- --- ---- -- ----- (If other than owner) FOR DEPARTMENT USE ONLY - --------- ----- ------------- ------------------------------ -- DATE --- --- -r�'--- ----•- ------ - APPLICATION ACCEPTED BY . --- ---- --- -------- --------DATE -------------•-�--------------------------- BUILDING -•'----------------- ----- BUILDING PERMIT ISSUED ----- ----- ----------------------------------------------------------- --- - ------- --------- ------- - -------------' ADDITIONAL COMMENTS ------------- -------- -- ------------------------------------------------------ --------------------------------------------------------------- ---- ----- ------- ------ ---------------------------- ------------------------ ---- - ------------- ----- _ �� --- ----------=------- - - Date ---- - ----------------------------------- Final Inspection _ _______ - - - - ------------------------------------------- - ---- - - -- SAN JOAQUIN LOCAL HEALTH DISTRICT r u 0 1-'68 Rev. 5M