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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------- --------- - - - - - j (Complete in Triplicate) Permit No. ----------- ----------------------- 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 Ordinancfee No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIO �� vt- - -- ---- ----- - -----------CENSUS TRACT -------------- ----------- Owner's Name ------ -�-- --s---- ----------------------- --- --------P ------------------------------------ one Address ?_//93 ----- -•------ , -- City ---------------------- ------------- Contractor's Name -------- --------------------- -----`-- `License # ------ Phone -----------. --------- ----- Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other --------- --------------- --------------- Number of living units --- Number of bedrooms.3—_------Garbage Grinder ------------ Lot Size ____________________-____-._____.____ . Water Supply: Public System and name - --------------------------------------------------- -------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ Peat E] Sandy Loam Clay Loam;❑ Hardpan ❑ Adobe'❑ 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 -----____- _-._.--_ W 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 0 Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ------------------- --------------------------------------------------------- -------------------- ------------------ Disposal Field (Specify Requirements) .__eo_�__ ___ ___- __ __'_ ____1Q =-e-__ __ _ __ y ----------- -- ------- ----------------------------- ----------- ------------------------ - ------ ------ -------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) 1 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 t Vlkman's CompensatitonjcLws of California." Signed ---- ----------------N-- -----I --------- --- -Owner BY --------------------------------- - - -- ------ --- --- ---- (if other than owner) FOR DEPARTMENT USE ONLY tet APPLICATION ACCEPTED BY ---------------------------------------------------------. DATE --441_-- - ----- BUILDINGPERMIT ISSUED ----------------------------------------------------- ----------------------------------- --------------DATE -------------------------------- ---------- ADDITIONAL COMMENTS ----- - - ------------------------------------------------------------------------------- ---------------------------------------------------------------------------------- --------------------------------- ------------------------------------- ----; =- ------------ ---------------- --------------------------------------------------------------- ------------------- ---------------------------------- ' Final Inspection by: -- Date ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M