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FOR OFFICE usE: APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Triplicate) ---------=----------------------------------------------- Date Issued -_---`�S_-�i --------------------------------------------------------- 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: ��r�r�' ---NO.Y ------------ - ---CENSUS TRACT ----3-y 7------------- JOB ADDRESS/LOCA ___�,-. - � -- Owner's Name ----- --- ------ -- - ---------- --- P ne t Address ------------- -� d � -- ---- �`.___�_-_-----. City ------------------------------ ' ----------------- Contractor's -------•---•-•--Contractor s Name --- ---- - -----'---------------- License # I - '_Y Phone --------------------------- Installation will serve: Residenceo Apartment House❑ Commercial ❑Trailer Court Motel ❑Other -------------------------------------------- Number of living units:___-1______ Number of bedrooms __---_'__------Garbage Grinder ------------ Lot Size __________________________________________ Water Supply: Public System and name --------------------------------------------------------------------------•- ----------------------- --------Private Character of soil to a depth of 3 feet: Sand'Q Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 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 eepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK' Size-_7" �X_ _�_'4'_-_ ----________ Liquid Depth __�_____________ Ca acit p y ��OG Type(— - ___ Material_)2-;--- ------- No. Compartments ______ ---------- Distance to nearest: Well ---------- -----------------__Foundation -----/Z9_........ Prop. Line .-.;5_^_/____--____ LEACHING LINE [ ) No. of Lines _________ Length of each line__________ _____ __ Total Length _-__ '-____ 'D' Box ----I------- Type Filter Material ---- _ —-----Depth Filter Material --------- _ ------------------- _______ Distance to nearest: Well ------_�r2_-------- Foundation ___l4!__----------- Property Line _____ .............. SEEPAGE PIT [ Depth ------ Diameter Number -_____-_vP-_-__________ Rock Filled Yes [ No Water Table Depth ----------------- -�Fp-----------------------Rock Size -- a / r Distance to nearest: Well ____________1�______________________Foundation ----(p------._--- Prop. Line ----- -____________ REPAIR/ADDITION(Prev, Sanitation Permit# -------------------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) ---------------------------------------------------------------------------------•--•----------------------__---------------------------- DisposalField (Specify Requirements) ---•--- ---- ----------------- ----------------------------------------------------------------------------------------------------- -------------------------------------------- ------------------------------------------------------------------------------------ ----------------------------------- (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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed --------- -------------- Owner By ------------------ -------------!�'-= -"--c r ---- Title --- ---- ----------- --- -------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------------------------------- DATE . �- /- - - ---------- -- - -------- ---- BUILDING PERMIT ISSUED -------------------------------- -------- -------------------------------------------- ----------------DATE ----------------------•------------------- ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- -- --- ----------------=----- - ------------------------------------------------------------------------------ - - Final Inspection by: __ __ - -- - - -- - -------------------------------- --- ---- -- Date - -rte' =�- -------•------•-•----- SAN JOAQUIN LOCAL HEALTH DISTRICT ( E. H. 9 1-'68 Rev. 5M