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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT /j (Complete in Triplicate) Permit No. ---- ------- F- Date Issued ------------------------------------------ -------------- This Permit Expires 1 Year From 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: L � JOB ADDRESS/LOCATI ` - ---------------------------_------CENSUS TRACT _______-___------------- - Owner's Name _/ ' F t = _t------------------------ - y --Phone ----------------------------- Address City ---- ---- ----- Contractor's Name - _ _C-7- _ _�? _ _l� __-_-.._ _ .___ _____________License # __ - dhone Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court Motel ❑Other _ ---------------------------- g —Oar age Grinder-4- -_____ Lot Size -_ Number of living units:_____ ___ Number of � roomts �" " ` ------------------ Water Supply: Public System and name __ -�__�t'_. __._.- �3�_ '-�_________-_________________________________Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt E] Clayel Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material 9 _ 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 ____________________________________________ 0 Distance to nearest: Well ------------------------ Foundation Property Line ------------____________ _ i SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes '❑ No i❑ Q Water Table` Depth ----------------- =-----------------------Rock Size ------------------------------- Distance to nearest: Well ----.-----------------------------------Foundation -------------------- Prop. Line ______________________ REPAIR/ADDITION(Prev. Sanitation Permit# -------__---------------------.--------------- Date ----------------------------------) Septic Tank (Specify Requirements) --------------- ----- - - -- ---------- ' -----------------------------•---------------------------•----------------------------- - y Disposal Field (Sp eci Requirements)-<----k-C ---/' ----si/f ----------------------------------------------------- - - � ' --------------------------------------------------------------- ---------------------- ------------------------------------------------------------------------- ---- (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 --- ------------------- -- - - ------------?-- ---- --------------------.7 Owner BY - -- -- Title ---t %--- --- --- (If other a owner) FOR DEPARTMENT USE ONLY -�� APPLICATION ACCEPTED BY --- -,`: ----------------------------------------- DATE .' T -7 BUILDING PERMIT ISSUED ___________ _... ------------------ ----------------------------------------DATE --------- --------------------------------- ADDITIONAL COMMENTS - - - ------------------------------------------------------------------------------------------------------------------------------------- ------------------------ -.� Final Inspection by: -- k ---- -------- --------- -------------------------- --------------------Date -------- __ -_ r�----=------- �'l - - - - - ---------•------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M