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FOR OFFICE USE: 3 o 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 compliance with County Ordinance Na. 549 and existing Rules and Regulations: JOB ADDRESS/LOCAT ON ._I�_f4-�-`-- -- - ------------------------- - -----�� ------- ------CENSUS TRACT S-�/------ -- Owner's Name -- ------ '� -------"�- ----------------------------- - - - -------Phonee----- Address ------� Q- � Cit b� U Contractor's Name _ __ As_ __ __ _ ___ _ _____License # 1Zr3&-?�Phone _-_____------_-____. -.______- installation will serve: Resident Apartment use-E] Commercial ❑Trailer Court ;❑ « Motel ❑ Other ---------- ---------------- 71- O Number of living units:.___ ------ Number of bedrooms s ------Garbage Grinder ------------ Lot Size ___ _ ------ - -_ _____________ Water Supply: Public System and name ---------------------------------------------------------------------- � ------------- ---------Private Character of soil to a depth of 3 feet: Sand'❑ 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, buildings1 etc. must be placed on reverse side.] NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is�vailable within 200 feet,] PACKAGE TREATMENT [ ] SEPTIC TANK 1 ] Size--------------------------------I---------_ ---- Liquid Depth --_----------------------- O 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 I❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to'nearest: Well _____________________________Foundation ____ ---- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date _______________________-__________) Septic Tank {Specify Requirements) -------------- - Disposal Fi ld (Sp if 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 Wo. an's Compensation laws of California." Signed ----------- --- ----------- ----- Owner BY --- --------- Title ' If other than owner) OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- ---------------------------------------------------- DATE . � BUILDING PERMIT ISSUED ---------------------------------------------- -------- --------------------------DATE -------------•-----------------------.----- ADDITIONALCOMMENTS ------------- ------------------------------------------------------------=----------------------------------------------------------------------------------- ------------------------------------- r ----------------------------------------------------------------------------- ------------------------------------------------------------------------------------ ----- ----- ----O�F.5 ----•---- " � Final Inspection by: ---------------------------------------Date- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M