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i FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. _7.z- -----------� ------ ----- �----"-- --------------------------------- 1 (Complete in Triplicate)� - ---- -------- ------- ------- ----- � Date Issued 3-"---------- is Permit Expires 1 Year From Date issued ____-_____ _ F ruct and l the work o const Application is hereby made to the ton compliance Local wiHealth District difor permit rmit t and existing Rulestalnd Regulations- ---- egutat o sTein described. This application is ma p �, ---- --CENSUS TRACT -------------- ---------- JOB ADDRESS/LOCAT ...... - - - -------Phone Owner's Name -- ---- - , ---------••----•--------------- - ' --•-- 1% / • ---• City ---- ------------------- -- Address -------------------------Ap?--- � 1 _T - 6Contractor's Name ----- -- -- - • -- - - S�7-yf/J License # /U�.��----- Phone -7---- Installation will serve: Residence r-1 Apartment-House 17-71 Commercial ❑Trailer Court ;❑ s Motel ❑Other __ - (r. t. Lot Size _ -,-�---(-��------•---•-- I Number of living units:_.__/._.__. Number of bedrooms:___--..Garbage Grinder _____. 3 - -------Private ❑ - -------------------- --- - - -- ------ - - - ---r------ Water Supply: Public System and name ------------------------------------ am ❑ Clay Loam El. Character of soil to a depth of 3 feet: ,. Sand'[] Silt❑ Clay ❑ Peat❑ . Sandy Lo Hardpan E] Adobe' Fill Material ------------ If Yes,type ---------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) itted if public sewer is available within 200 feet,) NEW INSTALLATION: (No septic tank or seepage pit perm Size. - ---------- - - Liquid Depth -------------------------- PACKAGE TREATMENT I I SEPTIC TANK[ - _________ p •- ------- No. Compartments ---------- ------ --- r Material______ Distance to nearest: Well ------------------------------------Foundation,- -------------- Prop. Line --------.-------• LEACHING LINE [ ] No. of Lines'- ------- Length.of each, line--------------- Total Length ------•-----------•--------- F Type Filter Material --------------------Depth Filter�Material ---------------------------•------------- 'D' Box --------- Pro er Line ------• Foundation_------- ------- ------ .Property p [ Distance to nearest: Well _________________ No SEEPAGE [ J Depth --------------- ____ Diameter Number -----------------------------Rock t=illed Yes C] _ Water Table Depth Rock Size a Foundation --------------- Prop. Line ---------------------- j Distance to nearest: Well ------------------ '�,' - .Date --------------------------- ;1 REPAIR/ADDITION(Prey. Sanitation Permit`# ----------------------- �. Septic Tank (Specify Requirements) ------------------------- ------- ---------•----- ----- ---•--------------------- I Disposal Field {Specif Requirements) ---------- - tX--- -- `Ae -""-" - -- -------------------------- ------ Y � z, x v ---------- - ---------------- ------ cep. ;1 . ----------------------------------------------------------------------------------------------- ---------------------- ---------------- ------------------------------- (Draw existing and required addition on reverse side) . . . _., r__ F I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin and,Rules and Regulations of the San Joaquin Local Health District. Home owner or licen County Ordinances, State Laws, - sed agents signature certifies the following: "FI certify that in the performance of the work for which this permit is issued, I shall-not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed --------- -�(Iifi -------------- - - - � �--------- Owner Title ------------------------------------ ---------- -i -- --- ----------- - - --------------- ------- ---- - thoer n owner) FOR DEPARTMENT USE ONLY I - -- - ------ ------ -------- ------� DATE=-� ---"------------- ----- APPLICATION ACCEPTED BY ---C_'T- _ --=- "---- - DATE ------------------- c! ---------------------------- BUILDING PERMIT ISSUED --------------------------------------------- - ..• _ _ ADDITIONAL COMMENTS ---------------- , Z �' , ,- ____-/-___=:° '' ------ ------------------ -------------------------------------------------------- ---------------- _ ------ -------------------------------------------------------- ------------------------------------- - �-- - --------------- ----- Date - 2 Z Final Inspection by: _�_-°---�-'------- - N JOAQUIN LOCAL HEALTH DISTRICT r N 0 1-'68 Rev. 5M