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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------------------------- (Complete in Triplicate) Permit No. ------------------ ---- --------i- `� -L-�_____________ 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/LOCATI_Ol .__vim ® -. ---- --------CENSUS TRACT ------------------_----- Owner's Name `,' - --------------------- ------------- --------- -------Phone Address --a' ----- - ----- -a I City - �` ----------------------------------------------------------- Contractor's Name ___ __ ___ - --- 4license # _r,�MY;?Y< Phone -------------- Installation will serve: Resid ce ['Apartment House❑ Commercial []Trailer Court Motel ❑ Other ---------------------- --------------------- Number of living units:-------/--- Number of bedrooms Z Garbage Grinder ------------ Lot Size --- _r - --------- 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 E?"f Adobe ❑ Fill Material ------------ If yes,type ______________________ p (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) -----� --._Z-[�-- --__ - �3 ----------------------Sc--=_ ��-----.fit-v,------- CY--------- '--------- ------- ------------__ - -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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: "1 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 BY ------------- ---------------------------- -a�`_- E 1 --- _ Title ------------- ---------------------- --------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B ----7 ------------------------------------------------------- DATE --- ------------- BUILDING PERMIT ISSUED --- ---------------------------DATE ------------------------------------------------------------ ADDITIONALCOMMENTS ----------- ----------------------------------------------------------------------------------------------------------------------------------------------- ------------ ---- - ----------- ----------------- -------------- ------------------------------------- ------------------------------------------------------- ------------------ - - ---- ------ ---- - - ------- --- - -- --- --- ------------------------------------------------------------------------ ----------- ------- - _ Final Inspection bY'"- ..� Date ' 7 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M