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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT . Permit No. M--V11 --- ------------------------ -------------------- (Complete in Triplicate) Date Issued This Permit Expires t 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: !! CENSUS TRACT -_-----. --- JOB ADDRESS/LOCATEON .��'��---�� -�'7N r--y-�- --- --� .--- - Owner's Name -- •----------- ----- -Phone --------------------------••-------- Address ----- --- -.- - - ------------ City �� --`----------------------------------------------•------ Contractor's Name ------- ------.License # ---- - --,-------------- Phone ----------------------------- Installation will serve: Residence F1 Apartment House'❑ Commercial ;[]Trailer Court ❑ Motel ❑ Other -------------------------------------------- Number of living units:___ bae Grinder Lot Size '----. Number of bedrooms - ___----Garg ____-------- ------------------------- Water Supply: Public System and name ---------------------- --------------------•----------------------------------------.-Private R] Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam 10 Hardpan Fx� Adobe_❑ Fill Material .__.-------- If yes, type ---------------------------- (Pl'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 sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size-------------------------- _ Liquid Depth -------------------------- Capacity ----•--- Ca acitY -------------- - Type .------------------- Material---------------------- No. Compartments -------------------••- Distance to nearest: Well -------------------------- -•-------Foundation -------------------.-- Prop. Line --------------------•- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ----------------------------- 'D_'-Box -_--------.-------•------- 'D,Box -.---------- Type Filter Material --------------------Depth Filter Material --------..----------•---------------------•- k Dist1 ce to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------•----- [ } p -------------------- Diameter ---------------- Number ----------------.----------- Rock Filled Yes E) No 0SEEPAGE PIT Depth C Water Table Depth -------------------------- .-----Rock Size ------------------- Distance to nearest: Well ----------------------------------------Foundation ---------------- -- Prop. Line --------------.-----•- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----__---------------------------I Septic Tank (Specify Requirements) ------- ------ --- ----- ------ - ---- -- _ '�$ Disposal Field (Specify Requirements) r'LIr r 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 vrith`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: "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." Signed ----CAaAla—,- Ac mt --------------------------------------------------- Owner By --------------------------------------------- Title ------------------------------- --------------------- ------------------ (If other than owner) At r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------------------------------- ------------ -------------. DATE ------------------ - BUILDINGPERMIT ISSUED --- -------------------------------------------------------------- -------DATE ------------------------------------------- ADDITIONALCOMMENTS ----------- ------------------------ ----------------------------------------------------------- -------- ------------------------- ------------------------------------------------------------------------------------------------------------------------------- --------------------------------------=--------------------------------------------------------------------------------- ------------------------------------------------------- -- ---- --- - ----- � Final Inspection bY: - - - ---- - - ------------ -------------------- ----------------------------------------------- Date/�. ------ ---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M