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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete,in Triplicate) Permit No: �tJ --�- -.0 -----------I- ----------------------------------------- - ____________________--------------- This Permit Expires 1 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 ismadein compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION --------------- CENSUS TRACT i h Owner's Na ---- ----- -- -- -------------- - --------------------- ---- - -----------------Phone ------------ ----------------------- Address ---- - l i ' Ci - ---- - -- { Contractors Name ----- --- - ------- ----- - -_---- - i -- -- ----- - ------ -----------------License # !__,�.g_3 -- -_ Phone ----------------------------- Installation will serve: Resi nce Apartment House E] Commercial ❑Trailer Court ;❑ Motel El Other ---------------- f ----- ---t Number of living units:______I_-__ Number of bedrooms __2�---Garbage Grinder ------------ Lot Size �_e..___- j Water Supply: Public System and name ----------------------_-------------_------------------------------- Private [� Character of soil to a depth of 3 feet: Sand'El Silt❑ Clay ❑ Peat❑ Sandy Loam • Clay Loam;❑ E Hardpan ❑ Adobe.E IIFill Material ----_ _.____ If yes, type --------------------- ------ 4 (Plot plan, showing size of lot, location of system in relatiod to wells, buildings, etc. must be placed on reverse side.) 1, NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK { ] Size_______ ------------------------------------------ Liquid Depth -------------------------- Capacity --------------- Type --------------- --f- Material---------------------- No. Compartments ----------•-•----=•--- Oct i Distance to nearest: Well ------------------ ----------------Foundation ---------------------- Prop. Line .----------------___-- 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 __________ai�___ Number _____.__.-- _--_-_______ Rock Filled Yes ❑ No 0 Water Table Depth -----------------------------.-``i----------------Rock Size -------------------------------- Distance to nearest: Well ---------------------- ----------------Foundation -------------------- Prop. Line ---------•---._..----- REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------ ------------- Date ___________ Septic Tank (Specify Requirements) - --------------------------------------- Disposal Field (Specify Requirements) --- {-- _-- - --- _ ------------------ - -.--- .- - - '_ 1 : d - ------------------- ---------------------------- (Draw existing and required l4 dai'iion on,reverse side)..v .', 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin i 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: "! 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 o Workman's Compensation laws of Calif`ornia." Signed ---- ------------- - ------ --- - ---- ------------------------------------ --- Owner r . BY - - !�-_ Title _ + y (If other than owner) . FOR DEPARTMENIT USE ONLY APPLICATION ACCEPTED BY ---- - - I DATE _. " �" -7 BUILDING PERMIT ISSUED ]{ DATE A �I') M ADDITIONAL COMMENTS ---- ------------------- ----------------------- - ----- = ----------------------------------------------------- • - ----- -- ------------------------------------------------------------ -------------- -_II ------------------------------------- ------------------------------- ---- - 1-------------- ---- - - ------ Final Inspection by: -- ---------------------Date a_'7l�-- ---------------- ----- =------ 14 ------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. SM.