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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. '--- -------------- ----------- f j (Complete in Triplicate) - Date�ssued ------------------- �� This Permit Expires 1 Year From Date Issued �f -- ------------ -- -------------------------- ---------- - -------- ii A lication is hereby made�to the .rloaquin Local Health Diistri dinan a for a permit and existing Rulestalnd Regulations:_l the work ein described. This application is made +njcompliance with County'0 ------CENSUS TRACT -_ �5� JOB rAQDRE55/LOCATION .I--- --- �.----- Phone 6.� , -" _ - Owner's Name - --------- -------•-- Address :k A3 License Phone fF_'E______ Contractor's Name _.7-2-: - --�J'1'------------------------------------- � „ I Installation will serve: Residence F] Apartment House,EO Commercial :Trailer Court ;[] ol Motel ❑Other _-_ ___ _ �t� d 'Garbage Grinder __._____ Lot Size _ __-. --- - Number of living units:--/i_�- -- Number of bedrooms I �� ------------------------------------------------------------------- Private Water Supply: Public System and name _ .',;�- --- . 1 �'Silt— --'Clay I Peat❑ Sandy_l.oam_❑ Clay Loam E] Character of soil to a depth;of 3 feet:y !Sand' ._ - - Hardpan ❑ Adobe E Fill Material ------------ if Yes,type _.---------- [Plot!plan, showing size f lot, location action of system in relation to wells, buildings, etc. must be placed on reversee�,,o I --- NEW INSTALLATION: (No septic,tank or seepage pit permitted if�ubl se r avaab able wit 200 feet,] i�, , �j :I� t . -- Liquid Depth PACKAGE TREATMENT [ SEPTIC TANK![e - t C acct / °f es ype�"!- 6 Materials �+ o Compartments -- - - 0, - P Y Jf T 1��® : -•-•---�� ll. a..�. Pro Line . I-------:--•--- } Foundation _ -_---------- .. P• Distance to nearest:tWell , --- ----- _ �� +_7:-;-.;Total Length f�--•----------- +. LEACHING LINE [L�No. of Lines _ --------- Length of each line__ - ��_ t� } =7—Type Filter Material04_Q�A7------Depth Filter Material 19-----------------------•---------- 1 D' Box i� 4 t - Foundation IQ---------------- Property Line. t y Distance-to near est: Well � - ---- --- _-^�-• - Rock Filled Yes .Q No 0 Depth �: °--- Number ---- -------- - ------ j SEEPAGE PIT [ ] I p '----= 1--- --- iameter ---------- . �- _�..,_ -t� — -4, i Rock Size ---- ------------------- - ater T,ble'Depth�--- ---------'------------- -- IM. rte`. , Y t Pro Line -------------- ------- Distance to nearest: Well ------------------ i Foundation #------------ p .il, ) REPAIR/ADDITION(Prev. __,. Date ------------- ---- Prev. Sanitation Permit#,�;_-�_:'-�-=_�-------- ------- -------- i :��: ,A i ---------------------------------------------- -,All Tank (Specify Rel uirements) -------- -------- Disposal Field (Specify Requirements} ------------------------ ---------------------- -------- ---------------------------------------------------- ------------------------------ f ______________________-______---_________-______.__ -------------------------------------- - _ - .---- ]Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will=be fdone in accordance with San Joaquin County Ordinances, Statel taws, and Rules and Regulations of the Sar+ Joaquin Local;Flealth District. Home owner or licen- sed agents signature certifies the following: " certify that in the performance of the work for which this pLrmit-is-issued,-_I.Shall.not employ any person in such manner i as to become subject to Workman's Compensation laws of California." ' i �� Owner Signe g f ---------- 8Y - 'F ---------- ----------- -Title {1 other than owner 11 FOR DEPARTMENT USE ONLY p ------------------------------------------------ 4-;x APPL1=CAT10N ACCEPTED BY Tt l )� DATE --------------------------------------•---- BUILDING PERMIT ISSUED .----------- ------------------------------------ -- ----------------------- ------------ ADDIy IONAL COMMEN , --- ------ -------- --------------------------------- --- ----- --- -'---------------------------- ---------------------------- _ ---- ------------------------------------------------ JF ----- _.F______ __ _ _ __________________________ v �I' _ _ _______ __ __ - --- ----- - ------ - -�------- ---- Date - ------------------- -- --„---- ' Final insp 'on b : - - - --------- - ' SANJOAQUIN .LOCAL HEALTH DISTR)CT. r, E. H. 9 1-'68 Rev. 5 A - a. !M.