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- 5 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -- ------ - ----------•-------------------- Permit No: .7.�-- - ' (Complete in Triplicate( ----------------------------- ----=-- ----------- Date Issued ---- -"�--7. This Permit Expires 1 Year From 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. 5 9 and existing Rules and Regulations: JOB ADDRESS/LOCATI -_D -- - --,--- �` , � ---------------CENSUS TRACT --------------•---------- Owner's Name _ - �+ -----Phone ------------------------------- City a.Jr Address _._ �? ---------------------------------------- . ---- -- ---- - �� - #� Contractor's Name -- - -- �-- ��---- ---------------------- License Phone Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer C - Motel ❑Other -------------------------------------------- , Number of living units:--/----- Number of bedrooms--------Garbage Grinder/ 0---- Lot Size --------- _ Water Supply: Public System and name .------------------------------------------------------ _________________________________Private j Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ Hardpan ❑ 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 1 W PACKAGE TREATMENT { ] SEPTIC TANK' e-- , - - - f Liquid Depth ----------------- ----------------- d Material_ �No. Compartments ----�--"---.---- Capacity/�� - TYP /yam .� / Pro Line _ Distance to nearest: Wel !6_a-____________________Foundation -"��-------- - p LEACHING LINE No. of Lines --__Z--------------- Length of Bach lin X --------- Total LengthZ;0_a------------- �- ,,.,�A_ epth ei/ Filter Material/- --------------------- -y -- --------- ---------`---- 'D' Box �. Type Filter Materia _ _ Distance to nearest: Well _ �__.--_tel Foundation - f Pro er Line, �� ,� ------- p �/ SEEPAGE PIT [ Depth l--- Diameter .�_- Number __l______________________ Rock Filled Yes No i❑ Water Table Depth ______Rock Size ____ •— c__ ----- P --fes --------------------------- - o . _ ... -Foundation ___ Prop. Line _ . ._�------- Distance to nearest: Well __� ��--=--;•----------- �-�-� -- REPAIR/ADDITION(Prev. Sanitation Permit# ----- �.. ------� ---- Date ---- ----------------------- ) -' --- ------------ --------------------- Septic Tank (Specify Requirements) ----------------?----- --•-----------------------------•----- i s * � � s.._r-.�.,—�.-.•,•ri`«—.r ---------------------- Disposal Field (Specify Requirements) --------- --------------------- .�-.-----"---------------- J - ' --------------- ----------------------------------------------------------- -----------------'--------_-- ----------------,�------------------------------ ------r--;----------------_-- y •-. ,......� (Draw existing and required 6ddition on reverse side) i I hereby certify that I have prepared this application and th-at-•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 net employ any person in such manner as to become subject to Workman's Compensation laws of Califoinia." Signed ------------------ ------- ---- - ---- ---------------------------- Owner -------------- ---- _ i I -------------------------- ..... --------- Title k { Title ------ ..__. (If of r an owner) 1 d t� FOR DEPARTMENT,.bSE ONLY AP,PL1CATION ACCEPTED BY ----- --- _------------- DATE __.-'l=_.._--- BUILDING PERMIT ISSUED ------ ---------- ---- j - ---DATE ---- ------- •--------------------------- V ,,... - ---------- -------------------------------- ---- �D,I�I�IONALCOAMMETS _ _ h ---------------------------- ------ -- - -- J.A--------------------- e ----- C- -----------------_------- ° Final Inspection by: -______ _ -------.Date µ ----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E.H. 9 1-'68 Rev. 5