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' FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) - Peimit No. ____ -------------------- This Permit Expires 1 Year From Date Issued Date Issued Z?'__11�.5'__.7¢- 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/LOCATIO � - -------- -------- -- -- - - ------------ -- ------------ -- - ----------- -----CENSUS TRACT - -- --------•----------- Owner's Name _.___ - -- - ----------- - �.....-- -Phone Address -- ----- -- ------------ --• City -------------- ------- - Contractor's Name --- ----------License # -- Phone ----------------------...____ Installation will serve: Residence 0 partment House,❑ Commercial:❑Trailer Court ❑ Motel ❑Other------------ - -- - - ----- - --- --- - --- Number of living units:.----- Number of bedrooms -------___-_Garbage Grinder ------------ Lot Size .- \• ______________________ { Water Supply. Public System and name --------_______ ___ _______--Private E� Character of soil to a depth of 3 feet: Sand Silt Cla p Q ❑ y ❑ Peat❑ Sandy Loam Clay Loam ❑ , Hardpan ❑ , Adobe -E] , 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 �`""c" � s P Y - ------------- --- Type -------------------- Material` ---- ------ No. Compartments ------------------ t. --- --------- �\1 Distance to nearest: Well ---------------------------------}_Foundation ---------------------- Prop. Line ---------------------- LEACHING --------- ,------LEACHING LINE [ j 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(Prey. Sanitation Permit# ---------.---- ----------------------------- ) { Date -__ -------------------•-•-------• r Septic Tank (Specify Requirements) _____________ _- i"sposal Field (Specify Requirements} -_- t- - , ,. " �1 ,.-------- �------- tt 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, I shall not employ any person in such manner as to beco a 1ubject to Work Compensation laws of California." Signed ---- -- ----t-------- ---- --- -- ------------------------------------------ Owner BY -------- ---- ------ , - ------ Title ---=------------------------------------ f other than owner) FOR .DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY -------------- -------------- ---------------------------------------------------------- -------DDAATTEBUILDING PERMIT ISSUEDES------_-�--.------a----- ---------- --------------------- i. 1TlONAL COMMENTS ---------------- ----- -- ---- 'r" -------•- --------------- ma Inspection by: ------------------------------- .Date --- -- ---- ---- ---------------------------------------- --------------- Final -------------- SAN __SAN JOAQUIN LOC HEALTH DISTRICT fi E. H. 9 1-'68 Rev. 5M.