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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------- -------- ----- (Complete in Triplicate) issued -------- ----------------------------------- = This Permit Expires 1 Year From Date issued Date 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/LOCATI ------- -- A4- ------------- --- p ------- ----- - ------Phone ------------------------------------ Owner's Name -----------""-" � y ---------------------------------------- _ -- -------------- ---- City --- -- S� -_ e---- ---- Address -- ---- ----- ---- ---- - Contractor's Name-"_ '�-1 ":.License #�I B _� Phone _ - ------------------ Installation will serve: Residence [Apartment House,❑ Commercial :❑Trailer Court ,❑ Motel ❑ Other i-------------------------- --------------- J '. Number of living units:-.---/----- Number of bedrooms ___ _Garbage Grinder 'T* --- Lot Size - Y '?- ----- ---- --------------------------------------- -Private Water Supply: Public System and name -------- __"" ------------------------------------ _ x Character of soil to a depth of 3 feet: Sand' ❑ Silt ] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ;❑ Hardpan �/ 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,) .2 PACKAGE TREATMENT ( I SEPTIC TANK [ Size---------------------------- -------- --- -___ Liquid Depth -_-- c� . Capacity # - Type -------------------- Material---------- - No. Compartments ----------------• Distance to nearest:`Well -------------------------------------Foundation .___.___ -------- Prop. Line ____________-_-.----•- � `Sa -�-- ------ Total Length -- 41�_,............... LINE [YJ No. of Lines -------I_______________ Length of each line__------------ .� - ... ... ,. 'D' Box ---�-- Type Filter Material __w s1 -------Depth Filter Material �"�------- ---------- Y i S • 10 Pro a Line. ---------- Dist 'nce to nearest: Welsh -------S'o -------__ Foundation ________________________ P �Y i"-- Number --------------I------------ Rock Filled Yes No SEEPAGE PIT [1(] Depth --- -o?-5-�-- Diameter ___-- e •, Water Table Depth = ----Rock Size ----3- .� y ------- r If Distance to nearest: Well ----------; pp--------=------ --.Foundation ---/-0------- ---- Prop. Line ------ ------•------- l ------V �--- Date ---------------------------------- ) REPAIR/ADDITION(Prev. Sanitation Permit# ---------------- ---------- - Septic Tank (Specify Requirements) ------------------------------------------------ 1------ -----------------------------------:--------------- --------------- - --------------- Disposal Field {Specify Requirements) ----------- ----- --------------------. ------------------------------------------- --------------=------------------- i -------- adC .--- '--- -_--------. = (Draw and required addition on reverse side] E I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin x 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 -___ Owner ------------------ By ---------•------------------------ Title ---- ------------------------------------ (If other than owner] FPR .DEPARTMENT USE 'ONLY i APPLICATION ACCEPTED BY --------------------------- - --------DATE ---------------------------------------- - DATE ---- ----------•------------------- - - -- - ---- -- BUILDING PERMIT ISSUED --------------------------------------------------------- ---- -------- ----------- ----------------- --------------------------------------------------------- ADDITIONAL COMMENTS ------------ ---------------- -------------------------------------- ------ --------------------------------------- - ---- ------- -------------------------------------------------------------------------- ------------ - - ------ _-_- --------- ------- -----------.------ --- -- - -- --------- ------- / -- ----- --- - tet` Final Inspection b - - ---------------------------------- - -- - - - ------- - - ------------------- - ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M