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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. -7� 3 --------------------------------------------------------- -- 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATI N '---�--------- - ---------------- -------------------------CENSUS TRACT -------------------------- ---- --- Owner's Name ---- - ---- Phone --------------------- -------------- Address9 -- ----- -----. City --- --- ---------------------------------------------- r Contractor's Name -- - ---- --- - ---- - --------- ` .License # �'�' F-�_ Phone ------------------------ Installation will serve: Residence ❑ Apartment House,F1 Commercial ❑Trailer Court ;❑ Motel ❑Other Number of living units:._'_.__ Number of bedrooms ___--- ____Garbage Grinder ------:7--� Lot Size ____ ------------------------------------- Water _________________________________- Water Supply: Public System and name ------------------ --------------------------------------------------------------------------Private ------------------ _ Character of soil to a depth of 3 feet: Sand'o Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam .g�` Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ____________________________ (Plat 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,) `� .r� Vl / F � PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size__; __X_y-___�__S___________________ Liquid Depth __ __.____.____________ a Capacity7-: Well _ T y p !w!aE ________ Materiai__dzry .�,___ No. Compartments __ -_......_... - Distance to Weare ______t.�'Q__ _______________Foundation -----Cp_..___s___________ Prop. Line _-_.s_______________ LEACHING LINE [ No. of Lines ---------I-------------- Length of each line_______S-�______________ Total Length ----S-0------------------ ' D' Box Y__-:___,:_ Type Filter Material ____a t__-__Depth Filter Material _____ _ __________________________-__-_- Distance to nearest: Well ____ -� Q'____.___ Foundation ...... o_----- .------- Property Line _A----______________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 ________________________________} SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------------------------------------------------------- DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------=------------------------ ----------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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: "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 ------ ----- ------------------------------------------------ itle - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ______ __ ------------- DATE --- y'_ -_7l_____-__________ - ----- ---- -- - ------------------------------------------------ BUILDING PERMIT ISSUED --- ---------- ----- - -------------------------------------DATE --------------------------- --- ------------ - - ---------- ADDITIONALCOMMENTS --------------------------------------------------------------------- -- ---------------------------------------------- --------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----- ----- --------- - - - - ---------- - - ---------------------------------------------------- --- -------- --- ------= Final Inspection by: --------- -- --- --------------------------------- ------- ---------------------Date _. -------71- ------- . _ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M