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APPLICATION FOR SANITATION FOR FOR-OFFICE USE: PERMIT �J Permit No: /--��-----• - -- ---- -- ----------------------- ' (Complete in Triplicate) ----- Date Issued ------------------------ --- ----------------- ---------------- ------------------------------------ This Permit Expires l Year From ate slue e work Application is hereby made to the San Joaquin Local itHealth Dyt0rdinrict orna permit 5Q9 and existing Rules tand hReg'u/llat Regulations App " Jf 7 b described. This application is mac Xcp ce !!'�� GC _CENSUS TRACT - - --------- ------ ---zn__ JOB ADDRESS/LOCATIO -- -- y�------ Phone--------------"---------------------- a Owner's Name ---------- ----- - r " Cj_:-cX -------------------------- ----------------- City _ =----------------- Address -------------------- : (�� --------License # -r -��---- Phone - ------------------- Contractor's Name ...... -- ` ` ° FResidence [Apartment House❑ Commercial :❑Trailer Court ',❑ Installation will serve: Motel ❑Other -------------------------------------------- Number of living units:____-- '! _ -- .Number of bedrooms ___o _._Garbage Grinder Lot Size ------------------ Private ' Water Supply: Public System and name -------------------- --------------------------------------- Clay Sandy Loam Clay Loam ' . Silt❑ Clay ❑ ❑ Character of soil to a depth of 3 feet: Sand'❑ Hardpan ❑ Adobe ElFill Material ------------ If Yes,type ----------------------------- must be placed on reverse side.] • (Piot plan, showing size of lot,elocation of system in relation to wells, buildings, etc. it permitted if public sewer is available within 200 feet,) ION: (No septic tank or seepage p NEW INSTALLATION: --" --- Liquid Depth --------- ---------------- ( PACKAGE TREATMENT ( � SEPTIC TANK�[ ] Size------------------------- ---------•-- -- Capacity --- ----- --- Type ------------------- Material==-------------------- No. Compartments -----•-----=----•----- Distance to nearest: Well --------------------------- --------Foundation ---------------------- Prop. Line --- --------- ----- _ Length of each -- line -------------------- ----- Total Length .--------------- --- --•-- - LEACHING LINE ["] No. of Lines ------------- "Llr . �. _ Type Filter Material ------------------ -Depth Filter Materia! ----------------------•--------------•--`--- D� Box --------- 4 Distance to nearest: Well ----------------- -- --- Foundation ------- ----- ----- -- Property Line ------------------------ � Diameter Number ---- ----------- Rock Filled Yes [] No [❑ Depth ---- ------- SEEPAGE PIT [ ] p ----------- - ` �— Water Table Depth _ _ ---------------------------- Rack Size k v Pro Line ------- ----------- Distance to nearest: Well ----------------------------------------Foundation ----- -------------- P- ----- ----- Date ----------------------------------) REPAIR/ADDITION(Prey. Sanitation Permit# --------------------------------- = _ ------------------ I ------------------------ Tank (Specify Requirements) ---------------- - _ ti y ---- ------------------- -------------- ------ \ (Specify Requirements) -- .. � -U - Disposal Field (Sp Y � - � - ------------- ------ ------------------- ----- 11 ------------------ ---------------------------------- _____________________________________ - __-----_________________._-------------------------------------------------------- __-___ ____ _ _______________________________-____ ,,_____._________________ w _ ______ jDraw existing and required addition on reverse I hereby certify that 1 have prepared this application and sthat of the San Joaquin Localbe-done Health strct.Home ace towner or Icer County Ordinances, State Laws, and Rules and Regulation " R sed agents signature certifies the following:•-w "I 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. t Owner _ Signed ----- -------------- ' `t. JL Title . (1f other than owner) t -r` FOR DEpARTMENT USE ONLY 00 DATE _ _."._ _�_" APPLICATION ACCEPTED BY _ -- - - ----- -------- ------ ----- - ------------- BUILDING PERMIT ISSUED -----------------------=-------------- ----------- --------- --------------- -------------------------- ADDITIONAL COMMENTS ---------- ------------ ----------- 4--/ -- --------------------------- ------------------------------------------------------ -------------------------------------------------- --- -- --------------------------------- - ----------- --- --- ----- -fL�_-- Final Inspectiontion by: - -- ---- -- - --------------------------------------- ---- ----- ----------------•------ ---------------------------- ---Date SAN JOAQUIN LOCAL HEALTH DISTRICT . i k E. H. 9 1-'68 Rev. 5M