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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT p --------- -------------------------------- Permit No: - ----�---- - (Complete in Triplicate) f, -------------------------------------------------- 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 unty O dinance No. 549 and existing Rules and Regulations: a JOB ADDRESS/LOC ION � `'fid ----------------------- ✓�'�-Ed CENSUS TRACT ,Q - ------------------------------------- -----------Phone _.---------------------------------- Owner's Name f- - �y� Address , z-� /(_------: - ...... City ------. -------------------------------------- Contractor's Name ----- ------ --- -=`-----/ -'License # Phone Installation will serve: Residence ❑ Apartment House 10 Commercial ,❑Trailer Court ;0 Motel ❑ Other Number of living units:-----I----- Number of bedrooms <__Y___-Garbage Grinder ------------ Lot Size ------ �---------- Water Supply: Public System and name ------- -------------------------- --------- ----------------------------------------------------- ------Private F Character of soil to a depth of 3 feet. Sand'❑ Silt El Clay E] Peat El Sandy Loam ® Clay Loam El Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ___________________________ (PI'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,l PACKAGE TREATMENT [ ] SEPTIC TANK fX Size_4 Ip.___X_-1�._.f'_4F___-- --------- Liquid Depth------- ______-_-__,..__ I 1 Capacity ._.j.zpogType _ - '- Material___ _ _ __ o. Compartments -_ -__________..__ 11 Pro Line____-_ __ Distance to nearest: Well SP - Foundation ___ - p. ` LEACHING LINE [I� No. of Lines _________z;?�--------- Length of each line-------g-0_14k-------- Total Length :_ _ -------- 'D' Box ------------ Type Filter Material ----- - .- _ Depth Filter Material ___ /F_�� _-__ ___________________ Distance to nearest: Well ------tea- __ Foundation -----/p_�______ Property Line _______ _ ____________� r SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number _.__---------------------------------- Rock Filled -Yes ❑ No wool Water Table Depth _Rock Size -------------------------------- V Distance to nearest: Well ----------------------------------------Foundation ______________ ---- Prop. Line -_______--______..__.- oto REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date -------------------------- -----1 r. SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------- ------------------•---------------------------- IDisposal Field (Specify Requirements) ------------------------- ---------------------------------------------------------------------------------------------------- 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: r "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 C mpensation laws of California." Signed ------------------------------------ Owner - By ---- � ---------- Title ---- -------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY L -------------------- DATE -.�_ -5__r- --- -------------- ---------- - - -----•----------- BUILDINGPERMIT ISSUED ---------------------------------------- -----------------------------------------------------------------DATE ------------- ------- --------------------- ADDITIONALCOMMENTS ----------------------- I---------------------------- --------------------------------- ------------------------------------------------------------ ---------------------------------------------------------------------------- ----------------------- ---------------------------------------------------------------------------------------------------------------------------------- i _ _ _ _ _________ ___ _ _-______________-------_______-_-___ _ -------_------- Final Inspection by. ---- �� -f .-- -------- � SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M _