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r FOR OFFICE USE: { APPLICATION'S FOR SANITATION PERMIT ' Permit No. ..................... "( A (Complete in Triplicatel '^ Date Issued ........�"— -73 .............................•---•---- This Permit Expires i 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. 549 and existing Rules and Regulations: 00 JOB ADDRESS/LOCATION ... :U:_... .t -- ._. ........CENSUS TRACT ..............::.......:.. Owner's Name ................. _. ....... .. ....... .. .... . ••••. -- ............ •----....... Phone ....... . Address ....---...-•---•---••-•-- ----- ------- --- •---------.... City ----- ..................................... 4 Contractor's Name .............. .. .... _ ..__..License Phone Installation will serve: Residence YAportment House,[] Commercial ❑Trailer Court 0 Motel ❑Other -------------------------------------------- r Number of living units:------ ____ Number of bedrooms ... Garbage Grinder,el_..._ .... Lot Size ..... Water Supply: Public System and name ..............................................................._ .. .....................Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay '❑ Pegt❑ �.Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe A Fill Material ....__....-. If yes,type ............................. (Plot plan, showing size of lot, location ofsystem in relation'to wells, buildings, etc.. must be placed. on reverse side.) 0� NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] I PACKAGE TREATMENT ( ] SEPTIC TANK i ] Size------- ........... ....... ........ Liquid Depth ................... _. Capacity .................... Type .................... Material No. Compartments Line ...................... I Distance to nearest: Well ----- .. Foundation .._--- Prop. LEACHING LINE [ ] No. of Lines ........................ Length of each line-------------------------- Total Length .......... 'D' Box ------------ Type Filter Material ....................Depth Filter Material ............................................ Distance to nearest: Well ........................ Foundation _..._...__.. ----------- Property Line SEEPAGE PIT ( ] Depth—____--------_-..._ ..Diameter ..._I.......... ...Number ......__........_..._._.__: .Roek Filled Yes ❑ No C Water Table Depth .......................................-........Rock-Size ........---••---......... ...... Distance to nearest: Well ........................................Foundation ............-....... Prop. Line`.----___..___-____---- REPAIR/ADDITION(Prev. Sanitation Perm V# _---------------------- - - ------- Date °_.-_.__.........._•----...--_---] Septic Tank (Specify Requirements) _. _._ 0- Pl . Disposal Field (Specify Requirements) ________________ __P.......:..-: ...........................•-•----•-.._.._..__....._....__...-----••. ............................... - ----------------------------------------- ------------------------------•--------- ---.............-----..........................------------------------- (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 Rulei and Regulations of the Son Joaquin Local Health District. Home owner or licen- zed 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 Workman's Compensation laws of California." I Signed ..........--•----...-- - ----= Owner BY ---....... . .L. ................................. Title ..-- L._............................................... .. I {I of er owner) FOR DEPARTMENT USE ONLY � y � APPLICATION ACCEPTED BY ._. ., .. :-------... DATE. . .�`�.., .................. k BUILDING PERMIT ISSUED ... .... ::..........`� i _ DATE-----..._- � .. ----•...............................••--••-............... - .....--••.......--•-• ` ADDITIONAL COMMENTS --- - :. ::::::::::::::::::::: ::::::::_ ::::::: 1 ...............I. Final inspection by: :.... .........................• ��5 .... Date .._._.. a .. .�?J.. SAN JOAQUIN LOCAL' HEALTH DISTRICT ' i E. H.13 24 1.'68 Rev. 5M 7/723-,%f