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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. --------------------------- ,► (Complete in Triplicate) �_'�--�-------------------- Date Issued ----- - This Permit`Expire`1 Year From Date Issued and l the work Application is hereby maodelso the an compliance cal withealth CounDtytrict Ord Warn a permit and existing Rulestalnd Regulations:described. This app JOB ADDRESS/LOCATION __ ----- �-�__�� - ------------------------ -----------CENSUS TRACT -------------------------- Name °` ---------------------- ----------------------------- Owner's Phone ------------------------------------ -- City _ � � --- - --- - --- Address - License # . �• Phone �� r _fir Contractor's Name __- - ------------------------------------ Installation will serve: Residence Apartment House❑ Commercial ❑Trailer CoVrt ❑ Motel ❑Other -------------------------------------------- ------------ Number of living units::------ Number of bedrooms ._-_Garbage Grinder _ .___ of Size " Private Water Supply: Public System and name __- ---------- --- -- ---•- ------ ----------" -- ----- -- - ---•-- ------------------ - Peat Sand Loam-❑ Clay Loam Character of soil tont depth of 3 feet: Sand❑ Silt❑ Clay ❑ ❑ Y _ y e ---------------------------- '...: Hardpan ❑ Adobe E] Fill Material ------------ If es,type (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 publicsewer-isavailable within 200 feet,) ,/. ?� s ~-- Liquid Depth _ ----------------- PACKAGE TREATMENT [ ] SEPTIC TANK Siz 014--=- .0 O Material ' __-.____ No. Compartments ---�-------------- Capacity ----- TYP - -- r -- ---------- Pro Line -��- ........ Distance to nearest: Wel _�,r-_. -_--------------Foundation _/� - P 4-01 ��" Total Length .- -"--"--------. LEACHING LINE ) No. of Lines ____s ------------ Length of each line__ _. ----------- � / -- ----------- ---------------------- D' Box _.. a Filter Mateilal,�g Depth Filter Material �� TYP �y �. Foundation ------ Property Line -�P----------•----- Dista a tc nearest: Well /-*�---4 4— �- /� SEEPAGE PIT j Depth ------ Diameters 7--.----- Number ____.�.___.__-__.---- Rock Filled Yes No ❑ ---�---------------- Rock Size/ rl- - Water Table Depth __ ___ ____________ ----- ----------- -- Distance td nearest-Well _ ------------------------- Foundation -0-2-0- ------ Prop. Line ..~�-_----- ' -----------------------.Date -------------------------- --------) REPAIR/ADDITION(Prev. Sanitation Permit =- ' Septic Tank (Specify Requiremer)ts) -__-_------------------------•- ---------------------------------------------- Disposal Field (Specify Requirements) --------------------------------------------------------""--""-""------- - - - - ----------- ---- ----------------------- -------- ---- - - - ;(Draw-existin- -- g and required addition on reverse si d e 1 hereby certify that I have prepared this application and thatthe work will be done in accordance with San Joaquin County Ordinances, State Laws, ar)d Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: person in such manner "I certify that in the performance of the work for which this permit is issued, I shall not employ any as to become subject to Workman's Compensation laws of California." • Signed ----------------------- ---- ---------------- - ---- - -- Owner- ' Title - _t----------------- �I' � (If of than owne FOR DEPAAJMtM MSE ONLY APPLICATION ACCEPTED Bl' .- =' ✓ j---- -- ---` ----- DATE --- 71------------------ BUILDINGPERMIT ISSUED ------------------ ------------------------------------------ -------------------------------------- DATE ADDITIONAL COMMENTS :, ----------------- ----, ---- - -- - - -- -- - - -- --- - - --- ------ _ .. - --- ----- =� , Date J -------------------------- ------------------------------- - _ - - �' f Inspection b -��'------ ------- ==�=- ---------------------------------------- SAN --- ----------------------------------------------------- Final - SAN JOAQU+N LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M