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FOR OFFICE USE: ---------- - APPLICATION FOR SANITATION PERMIT ----- --- ------•------ Permit No. •-- ---------- ------------ -- - -- --- - -- --------- ----- (Complete in Triplicate) ___________ This Permit Expires 1 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 com liana wit Coun y Ordinance No. 549 and existing Rules and Regulations: Lc a 9-- � -. � MICA-. - ' JOB ADDRESS/LOCATION ------ ` a - ------------- R � °" _ _ f�� -...............CENSUS r C'EGN'SUS TRACT -------------- -------- A� "` _Owner's Name ---- - - _ f-----------��------------------- Address ✓�Ya ------------ City - - i Contractor's Name __. ........ 'I.*S__:--------License # 9; - Z)__ Phone .._c�__ Installation will serve: Residence TI"Apartment House,❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other _._____ + ------- ---------------------------- Number of living units:.... Number of bedrooms _c�------Garbage Grinder 0---- Lot Size Water Supply: Public System and name -------------------------------------------------------------------- ---- Private Character of soil to a depth of 3 feet. Sand'v/ Silt❑ Clay ❑ Peat ❑ Sandy Loam -❑ Clay Loam ❑ Hardpan F ----Adobe'❑ Fill Material _N'0---- If yes;-type- — —_ y (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 flank or seepage pit permitted if public sewer is available within 200 feet,) q PACKAGE TREATMENT [ ] SEPTIC TANK'[ Size------------------------------------------------ Liquid Depth ------ ------------------- Capacity --------------------- Type -------------------- Material------- ---- No. Compartments --•--- Distance to nearest: Well ------------------------------------Foundation -_-------- ----- Prop. Line _.___.______-____-_ LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ----------- ---------------- 'D' Box -----------. Type Filter Material --------------------Depth Filter Material ---------------------------------•---.------. Distance to nearest: Well ------------------------ Foundation ----- ----- --- ------ - Property Line _--_ _-___-_.--_____-__ - - - _ SEEPAGE PIT [ ] Depth ____________________ Diameter _______________ Number ---------------------------_ Rock Filled Yes ❑ No ❑ Water Table Depth -------- --------- ---- ----------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION{Prev. Sanitation Permit# --------------------------- __-Date __________________________________) Septic Tank (Specify Requirements) ar) 7err - -� �� *�" - ---- ----�----f- Disposal Field (Specify Requirements) ---------------------: -------------- - ------- =---------------- ------------------------------------- -- --------- ----------------------------------------------------------------- ----------------------------------- (Draw ---------- -- (Draw existing and required addition 6n 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: Iti "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner u as to become subject to Workman's Compensation laws of California." i Signed ---------------------------------- --- - " Owner j BY Y�'' ` �- -�6 ' = Title (.fc'If other than owner) _ FOR DEP �TMENT USE ONLY' APPLICATION ACCEPTED BY - __ - ______________ ____ DATE ±ip BUILDING PERMIT ISSUED ------------------ --------------------------------- --------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS ------------------- --------------- -----------------------...------------------------------------------------ --------------------------------------------------------- ------ ------- --- --- ------ -------------- --------------------- - --- - - ----------------- ----------------- --------------------------------------------------- ---------- ------ --------------------------- -- -- -- - ---- --- - --------------------------- ---- ------------------------------------ Final InspecTi ----- ---- -----------------------------------------------Date ----- ..--. i SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M