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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �l (Complete in Triplicate) Permit No. ---------------------- This Permit Expires t 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/LOCATION . >"*7? ------------------------------------------------------------------------CENSUS TRACT --------------•------- Owner's Name 1-------- A -------------------------------------------------- ------ �`�_- -------------------Phone V-97/x'------- 6-- , Address _ r7--- - - ��4'� C / -------? ----------------------------- -------------------------. City --------------------- _l�e�f /` c aP --------------------- , _ Phone _ .�. ............ Contractor's Name __ �_ -_____,_ ______-License #r___ __ __ �l__---� ----- Installation will serve: Residence N Apartment House❑ Commercial:[-]Trailer Court C] Motel ❑Other -------------------------------------------- Number of living units:------1f__ Number of bedrooms --_-Garbage Grinder ___________ Lot Size _________________________________________•-_ Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------Private lW Character of soil to a depth of 3 feet: Sand'M Silt 0 Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ____________ If yes,type____________________________ (PI'ot 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,) PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------- _______________ Liquid epth -_-_______---____________. Capacity -------------------- Type -------------------- Material------- - ----------- No. Co artments ................. Distance to nearest: Well ____________________________________F dation ____________ ------ Prop. Line ____----__------------ LEACHING LINE [ ] No. of Lines _______________________ Length of each Ii otal Length -----------._ 'D' Box ___________ Type Filter Material __________ ________Depth Filter aterial -------------------------- ----------------- Distance to nearest: Well _____________________ _ Foundation __________ _____________ Property Line -•--____-•-------..----- SEEPAGE PIT [ } Depth ____________________ Diameter _____ --------- Number __________ ----------------- Rock Filled Yes ❑ No i❑ Water Table Depth ----------------- -----------------------------Rock ze -------------------------------- Distance to nearest: Well ___ -----------------------------------Fo dation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ----- -------------------------------------- Date ----------------------------------) . Septic Tank (Specify Requirements) ---------------- ------------- -------- Disposal Field Specify Requirements) ........._ _.__.� �`___-/ � 1 'f_ ---,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. 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, 1 shall not employ any person in such manner as to become subject t Workm Compensation laws of California." r- Signed ------- ------- --- Owner By ------- ----------------------------- Title (If other C----- than o - ----------------- owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ------------------------------------------------- ------ DATE -_ -•-------- BUILDING PERMIT ISSUED -------------------------------------------------------------------------------------------------------DATE ADDITIONALCOMMENTS ----------------------------------------------------------- ----------------------- ----------------------------------------------=------------- ........ -------------------------------------------------------------------------------------------------------------------- ------w---------•------------ ----------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------•---------------------------- -------------------- -------------------- - Final Inspection by: -------- --- ------Date ---�1- S -------•------ - ------------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M