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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. - This Permit Expires f Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 55,499 and existing Rules and Regulations: JOB ADDRESS/LOC -- CENSUS TRACT__ - ---------------- Owner's Name - - ---- ---------------------------------Phone -- ------------------------------------- Address -------- -- ----- - -------------------- -----------Address - ----- ---------- ------------------------•------ § r Contractor's Name - --------- -------------- - -----.License --- Phone ---------------------------- Installation ------- -------------------Installation will serve: Residen Apartment House,❑ Commercial i❑Traller Court 0 Mote ❑Other ------------------ ------------------------ /- Number of living units:---.. --___ Number of bedrooms __ 3___Garbage Grinder ------------ Lot Size ___-- ______-______ ------------------- Water Supply: Public System and name -------------- ----------....-..----------- Private Character of soil to a depth of 3 feet: Sand [] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam .0 Hardpan ] Adobe.E] Fill Material ----- ----- if yes,type ____________________________ i (Plot plan, showing size ,of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted ``if`` public sewer is available within 200 feet,) PACKAGE TREATMENT [ SEPTIC TANK Size `t.4� --.�" --- Liquid Depth _______�c� _ _______________ (� Capacity _1_ _ ____ Type _� __ __ ---- Material__ No. Compartments ___�______:.___ I Distance to nearest: Well ____________-r,___------------Foundation ________/0________ Prop. Line -------�____ .... LEACHING LINE ] No. of Lines _.__.--- ___________ Length of each line----_.__ O--- Total Length ,____�__ — _.______- i/ 'D' Box ____t_____ Type Filter Material __-___ __Depth Filter Material ----------/_ Distance to nearest: Well ----------5�:_ ..... Foundation -------Z-12__'_____ Property Line -------- --------- SEEPAGE ----_---.SEEPAGE PIT [ Depth ----d-2$7- --- Diameter ----2 , Number ----------o .__________ Rock Filled Yes [p No C Water Table Depth -------------- X01 r/ r� --- ---------------------Rock Size.,---=—�--L-��------�-3------ Distance to nearest: Well --------------Lf3___o____........----Foundation .... Prop. Line ..._.. _......... t REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date --------^______-_________________) ` Septic Tank (Specify Requirements) -------------------.------ .-____==_-- -------,----__—_-_ Disposal Field (Specify Requirements) -------------- ------------------------------------------------- ----- ------------ --- ------------- ----- ---------------------------------------- (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 County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "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 Workm s C mpensation laws of California." Signed -------- �----# --- Owner -BY �� --------- Title _ -rPc ----------------------------------- {If other tha FOR DI=PARTMENT USE ONLY APPLICATION ACCEPTED BY - ^"-L ----------------------------------------------------------- DATE ------------ BUILDING_ PERMIT ISSUED--------------------------------- ------------------------------------------------------------------------.DATE -- - ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------------------------------------- - ---------------------------------------------- = - ---------------- ----------------------:----------------------------_--------------------------------------------------------------------- ---------------------------------- ---- ----- ---------= ---- ---- ---- - -- Final Inspection bY: '� a t = Date Q l .SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M