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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ''// ------ I � ,t V, s Permit No --=------------------ (Complete in Triplicate) ---------- ------ --------------------- --------------- i This Permit Expires 1 Year From Date Issued bate 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. t _ -� I JOB ADDRESS/LOCATI 1-7 7� ------------------CENSUS TRACT _,:5_75 Owner's Name --------"-- -- - -------- - Ph neAddress City =l - --- --- --- - -------------------------------- 1 Contractor's Name --- - ----------- ------- P ._.License # -� 3Phone . Installation will serve: Residence*. partment House�❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other --- ----------------------------- Number of living units:-.----- --- Number of bedrooms ___.Garbage Grinder ------------ Lot Size -------------------------------------------- Water --------- ---------------------------Water Supply: Public System and name -------------- ----------------------------------------------------------------------------•--------- -------Private 3 Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Cl F] [ISandy Loom ❑ Cloy Loam ❑ Hardpan E] 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,) \�11 PACKAGE TREATMENT [ SEPTIC TANK'[ I Size__________ ___ __. Liquid Depth __._____.__________-_____ Capacity -------------------- Type -------------------- Material-------------------- ,No. Compartments ---.................... Distance to nearest: Well '_ -----------------------------------Foundation ---- --------— Prop.'Line --___--__-..-_.,. LEACHING LINE No, of Lines ___.___________________ Length of each line _.._�s�'--:-— Total Length ____-- [ J g g 'D' Box ----------.- Type Filter Material --------------------Depth Filter. Material -------------- --------------------•-- Distance to nearest: Well ________________________ Foundation .___ --------------- Property Line __'-______-___-__.____- SEEPAGE PIT [ j Depth -------------------- Diameter ---------------- Number----------------------------- Rock Filled r Yes '❑ No I❑ Water Table Depth ------------ m----`-----= -------Rock Size -------------------------------- Distance to nearest: Well --------------------/--------------------Fobindation -------------------- Prop. Line --'.----•-----._--..-- fIREPAIRfADD1TION{Prev. Sanitation Permit# ---------------- --:-:- --- ------ Date ---_------------------------------J Septic Tank (Specify Requirements) --------------------- -----------------------------------------=------- ------ --- �+ -------------------- -------------------------- Disposal Field (Specify Requirements) ---- -- - --------- a.(! -------- ---- -.�-' ----- 1 ------ -------------------------------I---------- � ---------- ------•---------------------------------------- ---------- -------------------------------------------,----------------------- ------------------ -------------------- {Draw existing -and required addition on reverse side) 1 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 suble .-,to,Workman's Compensation !laws of California." � Signed ---- --------- Owner. --- - ------------ --------------- BY r= Title ------ -- ----------------------. ' -------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ - - - _ /-'------ - - __-- ------- -- --- -- DATE/ - 4�---------------------------- l BUILDING PERMIT ISSUED -------------------------------------------------------------------------------------------- -------------DATE -------------------------------- i ADDITIONAL COMMENTS ---------------- - ---------------le------------------- ------------------------------ ---------------------------- ---------------------------------- ------ -- ----- -- -- -------------- ----------------------------------------------------------------------------------------------------------"-------- ----------------------------- - - --- Final Inspection by: _-OR----- -.- -- - -- ------------------------- -------------------.Date ------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M,