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soy-FIOR OFFICE USE- APPLICATION FOR SANITATION PERMIT Permit No: ---------------- ---- ----�.------ ------------ --- ------ ----- {Complete in Triplicate} G -------------------------------------------- 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION --------------------.. --g-7-------.. -----------------CENSUS TRACT ------- Owner's Name ------- ---- ------------------------------------------------------------------------- Phone ----------• n Address ---- ---------- --• Cit � _21 �------------ ---------------------------------------------- =- -----4'.a__ _.__��.� -------------------------- ----------� Y -=- Contractor's Name -------------------- ---------------------------------------M--------License # ------- -------- Phone ----------------------- ------ Installation will serve: '.Residence [Apartment House-F-1 Commercial:❑Trailer Court !❑ Motel F-1 Other -------2- ----------------------------•--- ` _- Number of living units----- ---____ Number of bedrooms --- ---__Garbage Grinder ------------ Lot Size .---- Priv te_ -- --- Water Supply: Public System and name ------------------------------------ ---------------------------------- -------------- Private_®� Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam:F_�_ 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.) 0.! NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) - ---- PACKAGE TREATMENT { ] SEPTIC TANK'[ Size----------15�---�-� =-------- ---- Liquid Depth ---,�_ __------ .- �U ( C%at-,F __ Material -c -- No. Compartments - Capacity -�S-- , ------- Type -- Distance to nearest: Well ......143C�--------------------Foundation -------I_a---------- Prop. Line --------6-----_------- ------4------------- Length of each line------QP.------------- Total Length _._o��p-------------- C� LEACHING LINE j ] No. of Lines .� 'D' Box _Yep___ Type Filter Material '-f -----.Depth Filter Material _____/ - ----- -------------------- Distance to nearest`1Nell ________________________ Foundafion _____. -_________ Property Line ---_ ----------------- SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ----------------------- -- ----------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -----------------.._-_ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) -- ------ -------------------------------------------------------------------------------------------••---------------------------- Disposal Feld {Specify Require n s] _____________ --------------------------------------------- ------------- ------------ ---------------------------------------------------------------- t _ ---- -- ---- -------------------------------- - - ------ --------------------------------- ------------------------------- ' -1004 4 --------------- ------ ------------------------- --------------- -------------------- ---------------------------------------------= r --- ------------ - (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, ( shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed --------------- ------------------- ----------- ---------------------------------------------- Owner ----------------- Title ---------------- - ------- ------- ---------------------------------- (If other than owner) FOR DEPARTMENT UAE 9MLY APPLICATION ACCEPTED BY --- -----------.i----- DATE ------ -_2`--------------------------- --------- i7•-------- BUILDING PERMIT ISSUED --------------------------------------- --------- ------ ---------DATE r ADDITIONAL COMMENTS -------`------------ ----- -- ------------- ---------------------- -------------------=-------------------------------------------------------------------------------------------------/DISTRlr - -- ---------------------- Final --------- - ----Final Ins ection b Date -_ --- - ----------- ------ SAN JOAQUIN LOCAL HEALT E. H. 9 1-'68 Rev. 5M