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FOR OFI9CE_USE: .rte APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No: ------------------------------- - ------------- t ----------------------------------- ------------- 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: t ons: ,. JOB ADDRESS/LOCATION ------- ------- -_, . CENSUS TRACT -------------+ D Owner's Name ------------------------C - -'--- _1 - ---------Phone _31-'__65-- A_.- Address -------- ---------- ----------- - - City - - --- - - - ----- ---- ---•-------------- Contractor's Name --------------- ------------ -- ------------------------License ----- ------------License # �.�f�------ Phone Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court [] Motel ❑Other Number of living units:------------__Number of bedrooms ------------Garbage Grinder ____________ Lot Siz ------- - --------•------------- Water Supply: Public System and name% ------------------------------ Private [� - ---------------------------------•---------- Character of soil to a depth..of 3_feetZap nd-'j]�--Silt-❑ Clay El Peat E] Sandy Loam ❑ Clay Loarr',N , an ❑ Adobe Fill Material ------------ If yes, type _______________-_____ (Plot plan, showing size of -lo't,klocation of system in4 relation to wells, buildings, etc, must be placed on reverse side.) NEW INSTALLATION: i ! {No septic tank or seep ge pith permitted if public sewer is available within 200 feet,) � PACKAGE TRE [ ] [ ] / r TREATMENT SEPTIC AN R r Size- `_.-: --�,--/ - - .-------------- Liquid Depth ------ Capaci#Y -------------- Type . --------------- Material--------- `t` No. Compartments -----------•--- ...... Distance--to-•nearest: Wel_ `f----- -----------------1------Foundation ----e-n---_--------- Pwrop. Line -----------I---------- No. -- --- w LEACHING LINE ----- nh e ------------•------.----- o a-togh --------------------- 'D' Box ------------ T 1 i # Type Filter Material __________..Depth Filter Material ___-___`1 --_ -� Distante to nearest: Wel! ------- ------------- NFoundation '=-------------------- Property Line ------------------------ SEEPAGE PIT+ Del th t ��# [ p ___f-- _- _- iameter _____ -__---- Number; ._ i--- --------------------- Rock Filled Yes ❑ No .0 . Water Table De tfS. --------------- ----- ---------- -- ---- ---- ....Rock Size '~ ----------- Distance to nearest: Well ---------_____ __ ' -_\-Foundation ____ _____ _____ Prop. Line _______--_--_:____.__ REPAIR/ADDITION(Priev. Sanitation Permit# _____ _ _ _ J --------- Dae -___ } ------------------------ Septic . -------------•---------- Se tic Tank (Specify Requirements) I '' E ► [ e Disposal Field (Spec y Requirements] __ _____ 1 -------------------------- f E _ ---- �.� r/: r . F_ . /, n �S �c --- ------------ ------ ---------------------- ---- M - I- / � �1* �--` (Draw existing and requirediaddition*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 ---------------------- f r _ Owner --------------------- . BY = F= . ... _ Title r R (If other:t a owner) DEPARTMENT USE ONLY APPLICATION ACCEPTE BY -------- - DATE ll=y� --------- BUILDING PERMIT ISSUED ______.___ � " ------------------ - ----- ---- -- ------------------------------------ ------- -------------------DATE ------- -----•----------------------------- ADDITION L COMMENTS ----- -- ----,-j------------------------------•---------------------------------.----- �l--�' --------- ► 33 v - tl ----- - - ----------------------------------- ---------------------- --- ----------------------------------------------- ------------------------------------------ ------ -- -r- - ------------------------------------------------------------------------------ -- ------------------------------------------- ----- Final Inspection by: ---- -- ---- - - - --- -------Date -- - - - - - -------------------------------- - - - - - - - JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ; - 4 i