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FO OFFICE!USE: _ T r APPLICATION FOR SANITATION PERMIT ---..--------------� Q�i1�? (Complete in Triplicate) Permit No. ---- � _ ---------------- ------------ - -------- •----��--- ---f-- 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 unty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIO 'lf 1 r ------------- --------CENSUS TRACT Owner's Name ---------- -- ---- r f/ -- ---------------------------------------------------- ------ - Phone ------------------ Address _ ll ----------------- C;ty Contractor's Name _ ly- � ------ - ------- - ------- - -- ----------.Li:.ense #v7-S"5�f_� -- Phone ------ ---------- ------------ Installation will serve: Residence,gApartment House°E] Commercial ❑Trailer Court ',❑ Motel [I Other ----- Number of living units:_____ Number ofUro ms ------Garba e Gender Water Supply: Public System and name __ ---- Lot Size - _�----U"----------- _-__ _ --- -- ------------------------ -------Private ❑ - - Character of soil to a depth of 3 feet: SandEl Silt-F-1ClayE] E] ❑ - Peat Sandy Loam Clay Loam ❑ Hardpan ❑ AdobeX Fill Material ------------ If yes, type --------------------------- (Plot plan, showing size of lot, location of system ;n 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,} PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size_________________________----------------------- Liquid Depth ------------------------- Capacity ------- ------------•--Capacity ------------------ - Type -------------------- Material---------------------- No. Compartments -------- Distance to nearest: Well ----- -------------------------------Foundation ---------------------- Prop. Line ---------___------ - ACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length g -----------I---------------- '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 .-----------_-_- _REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------•------•_---- ) Septic Tank (Specify Requirements) ------------------ ----- ------------- --- - ------------------------------------------- Disposal Field (Specify Requirements) ! --- -------- ---- ., - 3 x-a - ----- - --- - (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 beer e s bject to ork n's Compens ion laws of California." Signed --------------- ---- Owner BY - -- ------------------ Title - --- -- ---- ------------ (If other than owner) ---��- �--------- --� ----- -�-----�- �. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - - - - 7 - -------- --------- --------------------- --------- ---------- ------ DATE ----3=--I��L- BUILDING PERMIT ISSUED ------- --- - ---------- --------------------- ADDITIONAL COMMENTS ----- ----------- ------- - --•------ --------� - ---------- - DATE ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------ ------ ----------------------------------- ---- &- ----------------------------------------------------------------------------------------------------------- ---- Final Inspection b - - - -------- -L- -------- --------- -------------Date --- ------ ------------- E. ��-�----- ---------------- SAN JOAQUlN LOCAL HEALTH DISTRICT w E. H. 9 1-'68 Rev. 5M