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a F01 OFFICE USE: •: *APPLICATION FOR SANITATION PERMIT - C � � f o. 7 -3 ' - (Complete in Triplicate) Permit nK ----------- Date------ - ------ --- This Permit Expires 1 Year From Date Issued Issued _ II 1. --------------------- 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 . __L__v-1_------ ---------- �'.�---------------------------CENSUS TRACT -------------- ........... Owner's Name ------------- -";-L- .�/ -------Phone 6.3 .1 Address ------------------- ----- - - - Y ------------------------------------------- --------------------------------- Contractor's Name ___________ ----------- _ __ ____ __ ___- _.License # _f_-"_�?!----- Phone Installation will serve: Residence Apartment House,❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- _ Number of living units:__-- _____ Number of bedrooms ---- _.....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 V Fill Material ___________ If yes,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 public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size-----------------------------------.------------ Liquid Depth -_______------___.__----_. Capacity --------------------- Type -------------------- Material--------------------- No. Compartments ...................... Distance to nearest: Well ______________________--_-________-Foundation ---------------------- Prop. Line ...................... LEACHING LINE [ ] No. of Lines ----- ------------------ Length of each line---------------------------- Total Length ,____---------------------- '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❑ WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well -----------------------•______________Foundation -----------•-------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ________-___________----__--______) Septic Tank (Specify Requirements) ----------------•----- ----------------------------------------------- Disposal Field (Specify Requirements) ------------- T ------------------- ------------- ----------------------------------- ----------------------------------------------?�j_ tr a --,------- f'�'�'t'' --------------------------------- -------------------------- -------------------------------------------- ----------------------------------- -------------------------------------- --------------------------------------•------------- (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 to Workman's Compensation laws of California." Signed ---------- -- - - - -------- Owner Title BY ----- /_.11L ------ - --------- -. --•------------------------ - If er th caner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ------ ----------------------- DATE 'r BUILDING PERMIT ISSUED-_______________________-_ DATE -------------------- ADDITIONALCOMMENTS ---------- -------------------------•--------------------------------------------------------------------------- -------------- --------------------- --------------------•----------------------------- -----------•------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------- - - - ------ --------------------- --------------- ----- - ---- ------------ Final Inspection by: - --- -- `------ - C ---- ----- - Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M l�