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FOR OFFICE USE: ----------------------- APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. 1 - - 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: JOB ADDRESS/LOC ION .67OL�-____ _ ___ ___ _ __-- __a__ - -- ---------- ---- ----- ------- ---- CENSUS TRACT -------------- ----------- Owner's ---------- ------------- Owner's Name - ------ - ------ - - - ------------------------------- - _ Phone --------------•----- Address ----------------- V--- -- --- ----- ---- City -- - --- -_- ---------- � Contractor's Name _______ _ -__ �__ _ __.License # _! !l . l- Phone ---------------- ............. Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court !❑ Number of living units:-----/ Motel E]Other-------------------------------------------- _____ Number of bedrooms _-W----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 T- Fill Material _ If yes,type ---------------------------- (Plot _________________--______(Plot 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;[&� Size_s"X_l D_* S_'A°'----------- ---- Liquid .Depth ' --°-'----------- QIQ CapacityCt__ Type ✓_ Material._��r No. Compartments ---- 0 A i Distance to nearest: Well --------- _O_ -----Foundation __1_0___i----------- Prop. Line __, _._.___._____ LEACHING LINEf/ [� No. of Lines -______.z_______-__ Length of each line____________r________ Total Length -----LIP_'_____________ 'D' Box __y_-___ Type Filter Material ______�__k.....Depth Filter Material _______L4'__A-------- ................. Distance to nearest: Well -------•_5Q__�------- Foundation ----td,------------ Property Line _ _ S.- ._____ ...... SEEPAGE PIT [� Depth -----wPT------- Diameter ___.3�_'� Number __________ .2—----------- Rock Filled Yes ® No Col Table Depth t �L /0 �i P i-------------------------- Rock Size ��' Distance to nearest: Well -------------LDso__'___.__-----------Foundation ---1-v__-__-.__ Prop. Line _.5................ 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 Workman's Compensation laws of California." Signed --------------------- --------- Owner -------------------------- --- - - BY ------------------------- - - - .�'' Title ----- -------- ---------- -- -- ------------- ------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ___ _ _,_ DATE ----- ._----- _ .__�_._________ - - - BUILDING PERMIT ISSUED ------------------------------------------------------- ----------------------------------------------DATE _.----------- ----------------------------- ADDITIONAL COMMENTS ------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- ----------------------------------- - ?- ----- = e dFinal Inspection by: ---- -- ------------------------------------------------------------------------Dat "". - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M