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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No: _.____.____________________________________ ______ This Permit Expires Y Year From Date Issued _ Date Issued i 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 wit aunty O dinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LO N - r = --------------------------CENSUS TRACT -------------------------- ' Name --- -- ------- --------- Owners -City _ �] Phone C1` ! E Address -------- - i Contractor's Name _.__ _._ __. ----- _C _ License # -��- ?Phone -------------------_---------- Installation will serve:--- Residence Ap rtment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number of living units:___A!------Number`of bedrooms __�._-Garbage Grinder ___________ Lot Size ---�'L ��__-..r_____. Water Supply: Public System and name ---------------------------------• -------------------------- ---..---------- --------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loom .�k Clay Loam .C] 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,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size----------------------------------------------- Liquid Depth -------------------------- W Capacity ----- - - Type -------------------- Material---------------------- No. Compartments --------- -------=---- V Distance to nearest: Well ------------------------------ ----- ______________________ Prop. Line _--.___________-_____. LEACHING LINT= [ ] No, of Lines ________________________ Length of each line---------------------------- Total Length -------------------- ------- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------:----------------------------- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ----------------_----_ t SEEPAGE PIT [ j 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 ---_-_____________________________) SepticTank (Specify Requirements) ------------ ------- ------- -------- ------- ----------------------------- ----------------------------------------------------------- Dis (Sp -fy Requrements) -------- ------ - ---------- -- -- - --- - -- -- -- ----- --------------- b . - -_ -.--^ —O � _ _ - (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 Son 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 Work 's Campensatio aws of California." Signed ----------------------- ------ -------- -------- ------- Owner !� By --------------------------------- ---- ---------------- --- a- C' Title ------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION .ACCEPTED BY .- -'- 6-----------------------------------------------------------------------------------. DATE __..�� '�(`'�7�----------- BUILDINGPERMIT ISSUED ---------------------------------------------------------- --------------------------------=--------------DATE ------------------------------------------- G ADDITIONAL COMMENTS -- ---- ----------- ----- -- --------- -------------__ --------------------------------------------------------------------=--------------------------- ------------------------------------------------------------ - - ------- ------- __ - _ ----9------ Final Inspection by'-3_e--- -- .2` - -----------------------------------Date ---------- 7------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M