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tFOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ----7---—J---- -------------------- - '--------•---------- ---------- (Complete in Triplicate) / ----------------------- Date issued -- X02 � -- ----------------------------------------------- ------- This Permit Expires I Year From Date Issue Application is hereby made to the Son Joy quin Local Health District for a permit to and existing Rulesstruct and tall the work and Regulations described. This application is made �p�.glanc w t Cou t Or 'n . +�`� �` -�'- f` Lcics�,ti - -CENSUS TRACT -------------------------- JOB ADDRESS/LOCATION _ - Phone = Owner's Name = ------ - - � _ - - ----- City Address ------------- ----` f-%--------- (L = if 3 �'- Phone i �+-v License # --�..-. --------------- Contractor's Name __-""------------ --- -- - . --------=------ - I Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court•;❑ --- Y ( Motel - nder z.. ----------------------------------------------- ' 'GdrbaLot Size ---------------- Number of living units:-y :-------.Number ofdrooms --------- geGri ,- ---------Private------------------------------ [ _... Water Supply: Public System and name ------------------------------- Cla --------- Peat Sandy Loam --------❑ Clay Loam.0 Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Y E] , Hardpan ❑ Adobe-E] 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.) I � NEW INSTALLATION: (No septic tank or seepage pit permitted if.-public sewer is available within 200 feet,) I : - ----- Liquid Depth -------------------- PACKAGE TREATMENT SEPTIC TANK![ Size------''-- ---------------------------- Material -------- No. Compartments -----------------. --- �. Ca acit Type- ---------------- � Distance to nearest: Well ______________ ___ --- I---- -----Foundation ---------------------- Prop. Line ----#------•- ------_ Total Length -------•--- ------ LEACHING LINE [ ] No. of Lines ------------ .Length of each line-________ - \ I _Depth Filter Material --------------------w------i------ ---------- 'D' Box ____.___---- Type Filter Material ---------i--- ----- Distance to nearest: Well Property Line t Foundation P tY �- " Rock Filled Yes [� No i❑ SEEPAGE PIT [►� Depth ----- ---- ------ Diameter __ ------- Number ---- ----------------- O, © ? _Rock Size .- ------ 3--------- j Water Table Depth -------------------------- ---,-------- $ ` Distance to neare'sl'': Well.__'___ --50------t-----------Foundation ------1-40.---•--" Prop. Line -----------•-- ------- + ------t------------- Date ------------------------------- ) REPAICtfADgITION(Prev. Sanitation Permit# ------------ ------- -- ..,, A ! ' -= ------- ------------------ ---------- ----------------\ Septic Tank (Specify Requirements)!--- -------------------- Disposal Field (Specify Requirements) ------------- ------------------------------------ :--- ---- ----------------------------- -- ------- ------- ----------------------------- ------------------- -- tI i ' - -----_._-_ - - - ------------------ ------ {Draw existing and required addition on reverse side) - . I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin, r f County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or llcen- ' sed agents signature certifies the following: k for which this permit is Issued, I shad not employ any person in such manner "I certify that in the performance of the wor as to become subject to Workman's Compensation laws of California." Signed " tet. -- Title ` y __ Owner BY LJr {If other than owner) FOR DEPARTMENT USE ONLY DATE /--------------- APPLICATION ACCEPTED BYX. -- - -- - ------------------- -- -------DATE - -------- --•----- ------- -------- ------ BUILDING PERMIT ISSUED ------------------------- ------------------------------- ----- ---------- ------ ADDITIONALCOMMENTS -------------------------------------------------------- ------------------ -- ---------------------- ----------- ---------- ---------- ------------------------=------------------------------------------------------------- - - ------- I - --____________________________"_ _Final Inspection by - - - -- -- --- - - - - - - ---------- ------- -----------.Dat -d- ------- --=---- ---SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev..5M.