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FOR OFFICE USE: PPLICATION FOR SANITATION PERMIT -------------- ------------------------ Pe ------- (Completein Triplicate) rmit No: --------- ----------------- --------------------------- �. This Permit Expires 1 Year From Date Issued • Date Issued _ _ _ _ _ ---------------------------------- ---- -- - Application is hereby made to the San Joaquin Local Health District for a permit toconsd install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: 2 ----'� ------°---------------CENSUS TRACT -------------- ------ JOB ADDRESS/LOCATION .--.-.�-�_��---- ----_--�" .- Owner's Name _4/1 + 'Al...... -,l�------------------------•------------------------------- -------------------Phone X?__14- �------•- i Address ---------- 2 ',ot---- --- - - - . ----------------------------- City -, ' Contractor's Nam ------------------------------- -----------------------------.License # ------------------------ Phone ----- ------------------------ Installation will serve: Residence X Apartment House❑ Commercial :❑Trailer Court El Motel ❑ Other --------- ---------------------------------- ®O Number of living units------------- Number of bedrooms ---3------Garbage Grinder -.-- ------- Lot Size ------- ----------- Water.Supply: Public System and name - ------------------------------•--------------------------------------------------------------- -I------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Same Clay Loam X. Hardpan Adobe'❑ Fill Material ------------ If Yes, type ---------------------------- (Plot --_-----.-_-- _-(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,] 4 , PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size-------------------------------------------.- -- Liquid Depth --------------------------- tl\ Capacity -- ---------_---.--,----- Capacity ----------- -------- Type -------------------- Material--------------------- No. Compartments ------------------ ---- " pv Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line --------------.-------- i LEACHING LINE [ ] No, of Lines --- ------------------ Length of each line---------------------------- Total Length ------------ ---------------- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- t Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------------ ` SEEPAGE PIT [ ] Depth -.--___-- -Diameter ---------------- Number ------ .------------------ Rock Filled Yes ❑ No C]+ Water Table Depth --------------------------------------------------Rock Size ---------------------------- Distance to nearest: Well ------------------------- -----Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit L# -------------------------------------------- Date ----------------------------------) iSeptic Tank (Specify Requirements) ----i----------------------- ------ /--------------YX-+-----------------------------------:--------------- :-- ------- Disposal Field (Specify Requirements) e �` �-------------=--------------------- • ----------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------ - ------------- ---------------------- -------------------------------------=-----_--------------------------------------------------------------------------------------------- (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. Nome 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 subje to W7�rkman s Compen a ;laws o c- ornia." Signed '� -�-- �--- � -------�- -- - -- Owner By ----------------------------------- ---- ------------------------------------------- Title ---------------------------------- - ------------------------ (If other than owner) FOR .DEPAStTMENT USE ONLY 4 - - APPLICATION ACCEPTED BY DATE -- -:/ '-.'� BUILDING PERMIT ISSUED -----/ s - _'KA----------- ------ DATE -- ----- --------------------------------- ADDITIONAL COMMENTS --.��__�� .�r - - -- -- ------------------------------------------------------- -------------------------------------------- ---------------//-----------------------------------:= ----- --------------------------- ------- '---------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ----- ------------------------------ -------- ---------------------------------------- -------------------------------------------- --- --- - -- - - --- Final Inspection --.-Date "y ---------.� SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M 4