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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -----�------•---------------- -- Permit No: (Complete in Triplicate) This Permit Expires l 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 is Ae0 n comgl}ancg,�t upty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .- ----- ----- --------,-v. IV ------------------------------------------ ---- -------------CENSUS TRACT Owner's Name ---- I r ------------ - -----------Phone ---------------------•-----------•-- / •y� I Address ----------------- 0-1 ' ---_/1--- A ------ --A------d------------- City y Contractor's Name - -- rG _ -----=--------License # _�� ------ -Installation _ Phone -Install at ion will serve: Residence Apartment House�❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number of living units:._____---- Number of bedrooms ________Garbage Grinder --------- -- Lot Size _ _________________ ________----.___ I q ' Water Supply: Public System ands name ---------- -------------------------- ----------------------------- ' ------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay'E] Peat E] Sandy Loam { Clay Loam ;❑ Hardpan ❑ ,• Adobe 'I] Fill Material ------------ If yes, type ---------------------------- JPlot 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,] RC1 k F it PACKAGE TREATMENT j ] SEPTIC TANK [ ] is Size-----------------------------------•------------ Liquid Depth -----------•---------"_--- ;. _ ... _ F: �. Capacit ---------------- - Type�:w-------•=---=--- Material---------�----------- No. Compartments ------ ;F � . _ _____________ -------- ---------------- Prop. Line -------------------•--Distancepto_nearest:_Welf____ � Fovndafiion LEACHING LINE [ ] No. of Lines __'_1_"�__ _'• Length of each line---------------------------- Total Length ________"- �T 'D' Box ----------- Type Filter Material --------------------Depth Filter Material -------------------------------------.------ ``� Distanced to nearest: Well ------------------"""--- Foundation ------------------""""-- Property Line_ ------------.-------__-- SEEPA G E.PIT [ ] Depth _.l---------.------- Diameter ---------------- Number -------------------------- - Rock Filled Yes ❑ No Water Table Depth ------------------------------------------------Rock Size ---- --------------------------- I Distancel,to nearest: Well ________________________________________Foundation ------------ ------- Prop. Line _____.----__________-_ REPAIR/ADDITION{Prev. Sanitati�n Permit# -------- ----------------------------------- Date ------------------------------- I' SepticTank {Specify Requirements) --------- ---------- -------------------------------------------------------------------------------------- ---------------------------- I 0c Disposal Field[(SpecAy Requi�ents) ----- •4_0 1 -------- ------ ---- - ~- --------- --------- ---------------------------------------------------------- ------------------------------------------------------------- ----------------- -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 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 subject to Workman's Compensation laws of California. Signed ------------------------ I -- -------- ------ -------- Owner BY = � Title - (If other than own ed i I� 11 FOR .DEPARTMENT USE ONLY p,0:7 APPLICATION ACCEPTED BY .__- DATE - - ------------------------ BUILDING PERMIT ISSUED -------='t-----------='=------------------------------------------ ----- --DATE ------------------------------------------- ADDITIONALCOMMENTS --------:0-------------------------------------------------------------------------------------------------- ------------------------------------------------ ai r ---------------------------------------------- 1!.---- ------------------------------------------------------------ ---------------------------------------------------------------------------•--- _ P Y - - ----------------- --------------------------------------------------------------- --------- ------------------------- i Final Inspection b -------- ----------------------Date SAN JOAQUIN LOCAL HEALTH DISTRICT r E. H. 9 1-'68 Rev. 5M