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- FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -----_--------------------------=----------- -------------------- (Complete in Triplicate) Permit No. ---------------- This Permit Expires ] 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ±. '--- a(----------------------CENSUS TRACT --------------•------_-___ Owner's Name ._ t - --- -------- -- ------------------------------------- r Phone -- - ---- ---------•------------- Address . r`�� City - ------------------- Contractor's Name C2 -h - License # _��e(_3_�Y Phone ------------- Installation will serve: Residence - Apartment House Commercial :❑Trailer Court ❑ f 1j � Motel ❑Othi er ------ --------------- ---------------- I Number of living units:------ Number of bedrooms _3-------Garbage Grinder ------------ Lot Size --_____________________ ._ Water Supply: Public System and name ------------------------------------ ___.-________Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam RT" Clay Loam;[J I Hardpan ❑ Adobe '❑ Fill Material If es, E --- Y type --------- ------------------ 1 (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,) p� 4 PACKAGE - Ir TREATMENT [ ] SEPTIC TANK [� 5ize-�� ' �` y� .r-`r - Liquid Depth . -----------•------- Capacity _l obType --- Material--- -e _,--- No. Compartments 6 Distance to nearest: Well -.------5 _ -----:-,--:---=Foundation ----- °-_---------- Prop. Line -- .5___,-._------__K LEACHING,LINE No. of Lies -of, each line_ - Total Length -- -f_-.............. `! ---_yLength � -- - D'tBox .__ --- Type Filter Material r---__:_ S_ � _=Depth 'filter' Material -_____---/_f------.______________________ Disance to nearest: Well ---- Foundation Foundation -----L#__'__________-- Property Line __S------------------- SEEPAGE PIT [ j Depth Diameter -- � Number ---------------------------- Rock Filled Yes ❑ No C] 1 Water Table Depth -------------------------------------------------Rock Size -_ c, Distance to ne,arest:,Well _____t'f____________________________ Foundation -------------------- Prop. Line ____.___._.._____ ----- REPAIR/ADDITION(Prev. Sanitation Permit# __________ -------- ___ --_ _._ * --____-__ Date ---- Septic Tank (Specify Requirements) ____________________._ --------------------------- Disposal Field (Specify Requirements) _________-_ ------------------------ ---------------------------------------- ---------•--------------------------------- r--- ---------------- 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 or1licen. sed agentslsignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ------ -------- ------------------- -------------- ----- Owner ` -----------,-�----,/--�---- ---- BY ------ ------- --------- ¢ Title Q. f _ ---- ------------------------ ot er than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -4 -- _ ---------------- ----- ------• DATE ------------------------------------------------ -- BUILDING PERMIT ISSUED ---- ----------------------------- --------- -----------------------DATE ' ADDITIONAL COMMENTS ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ------------------------------------ --------- -- ------ --Final Inspection by: .__ _ = ��------ --------------- ------------------- ------------ ------------- - �`�---/ ` - .Date -----•------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.