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EOR OFFICE USI: APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Triplicate) Date Issued This Permit Expires 1 Year From 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: - r .CENSUS TRACT -------------------------- JOB ADDRESS/LOCO TION / G._ - .. ----- - -. 2v ✓.. ----------- Phone Owner's Name . . . .- ---------- - Address -. W-•-..--� City s ` �.�__ ' License # -� -- �. Phone ------------------------------ Contractor's Name - ?,l. y- - -- . �'� Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other _ ------ ---------- - ---------- Number of living units- 1._.. - Number of bedrooms .__...-Garbage Grinder ------ - Loi Size - -.- Private Water Supply: Public System and Warne ------ -------- ----- -------- ------------------------------------------- ----------- ------•--- Character of soil to a depth of 3 feet: Sand [! Silt ❑ Clay ❑ Peat❑ Sandy Loam E�r Clay Loam '❑ Hardpan ❑ Adobe ❑ Fill Material .__ -------- If yes, type ---- (Plot plan, showing size of lot, location of systems 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,) I i ,, 1 PACKAGE TREATMENT { I SEPTIC TANK V � Liquid Depth --.---- ------ -Size--5--_/�'-1�-,-t�_- - - - Capacity c` ___ --��-�- No. Compartments -_- ---------- Material 1� _ "_--Type `"�_ Distance to nearZi Well ..... mac_' ' - -•------ --Foundation . 1.0.t --- - Prop. Line --->---- ---------- LEACHING --LEACHING LINE ['� No. of Lines ---------- - Length of each line__ r Total Length -_+ -y0'---------_-- 'D' Box --L ---- Type Filter Material _n__72------ Filter Material ---.---1- --r------------- Distance to nearest: Well _..-�SV.-1----..----- Foundation -------�. Property Line _.. ----------------- SEEPAGE PIT [ Depth Diameter ----------- ---- Number - ----- ------------ ------ Rock Filled Yes EJNo Water Table Depth ---.-------- ----------Rock Size ------------------ ---------- Distance to nearest: Well ---------------------------------------_Foundation ------------------- Prop. Line ---------------------- t REPAIR/ADDITION(Prev. Sanitation Permit'# -------------- - - - -- -------.- Date ----------------------------------) Septic Tank (specify Requirements) ----- ------ ------- ---------------------------_ --- - --- -- ----- •--------------------- ------- Disposal Field (Specify 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 Work 's Compensation laws of California." r Signed _ _ _-.___. Owner i By --. ---- ------ r1C ` L Title . . - (If other than owner) FOR DEP-RTMENT USE ONLY APPLICATION ACCEPTED BY -.-- . F -- DATE BUILDING PERMIT ISSUED --------- -- ---..DAT -- ------------ ----- ADDITIONAL COMMENTS --------- --- -- ----------- -- --- --------------------------------------- --------------------------------------------------------- --- -------- ------- ------- --------------- --------- --- Final Inspection by: i Date .Y `1s, ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M