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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit II vim -------------------------------------------------------- (Complete in Triplicate) ------------------ -- ------------------------------------ Date Issued 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 Ordinanc No. 549 and existing Rules and Regulations: -------------CENSUS TRACT ------------- JOB ADDRESS/LOCATION ._�4-- - __ Owner's Name __. ----��'"��-----��---------------- ---------- ---------------------- - - Phone - --------------------------------- City -��-- - ------�---- --- ----- ---------- ---------------- . ----------- -------------------------------- : / Address -------- --�-��'."-------------------• _ ___.License #/lf Phone - Contractor's Name ___-___ _ "'' -'��-- ---------" ------ p Installation will serve: Residence Apartment House❑ Commercial:❑Trailer Court ❑ Motel ❑Other ------ ------- "---------------------------- der -1Y-g Lot Size Number of living units:__----- Number of bedrooms Garbage Grin ___'eL" �, •----- Water Supply: Public System and name _.___________________ ---- Private ----- -- --------------- Character of soil to a depth of 3 feet: Sand'[:] Silt❑ Clay E] Pea#ElSandy Loa mClay Loam E] Hardpan ❑' Adobe ❑ Fill Material ------------ If yes,type ___---__..________________ I (PI'ot 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 er is available within jqu�2� ptht, - ---_-,----- PACKAGE TREATMENT [ ] SEPTIC TANK ize. --_ _ Materia!_ No. Compartments _ �` _----. - -- CapacitY Type / //�� Foundation ----------- Prop. Line 1-------= Distance to nearest: Well __-____��--------------------- � �--�-- 1 Length of each lin f-- - Total Lenges / F LEACHING LINE No. of Lines -_S---- f '� " `D' Box -_ Type Filter Material � -V -Depth Filter Material ,4107 ---------•----------•------------ 4 �� y r Distance to nearest: Well ,- ------- Foundation --------- Property Line --- -- --..----- SEEPAGE PIT [ ] Depth ------------------ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0+ Water Table Depth ------------------------------------------------Rock Size --------------------------------f ------Foundation -------------------- Prop. Line -•-----•-------------- Distance to nearest: Well __-________"_____-___� --- ----------------------- Date ----------------------------------- Septic _----------------------------- --1 /. REPAIR/ADDITION[Prev. Sanitation Permit# _____________________ . k Septic Tank (Specify Requirements _-_---------- ----.------------" --------- Disposal Field (Specify Requirements) __________ ------ ----------- ------ ----------------------------------------------------------------- [ . t ---------------- ---------------------------------------- ---------------I------------------------------------------------=•--------------------------------------------------------------------- (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 "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' ompensati.on laws of California." Signed --- ------- ------------------------------------------------- Owner ' Title _.( f�.,1! ------------------------------- 0 ------------------------------ other t owner I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - -- -- --�"/'----------------------------- DATE -�D ------ - ------- -- -- --- ----- ----DAT ------------------------------------- ---- BUILDING PERMIT ISSUED -------------------- ---- ------------------------------------ - ---Z ------------------------------------------=--------------------------- ADDITIONAL COMMENTS --------------------- ---------_ - - ------------------- - -------------------------------------- ------ ----------------------------------------------------- - - ---- - ---------- ----------------- -- - ---------------------------- - - ---- ----- -- - - ------ Final Inspection by: .__ -- --- ---------------- -------- -- --- -- -t--�----°------ ---------_-------------- ---Date -- ----- ------- -- ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.- 9 1-'68 Rev. 5M