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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. _.71------------- - ---------- -------------- 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/LOCATION :?- __- ------------- S` ---_ CENSUS TRACT - -- - -- Owner's Name ------ .. __ � - ----- --- -----------------Phone --------------------------• Address ? Cit ., Y- ------ t-_ = ------------------------------ Contractar's Name ---- ___ _ License # _[��_ --- ❑ - ��"•: Phone - --------- ----------• - Installation will serve: Residence y Apartment House . `Commercial []Trailer Court ;❑ i` Motel ❑Other .----------------------- -------------------- Number of living units:_.-_--r__._ Number of bedrooms _-__-Garbage Grinder --------- Lot Size ___-a. .r ------ y Private . - ----------------------------------- - Character of soll to a depth of 3 feet: Sand'❑ Silt❑ Clay 211" Peat E] Sandy Loam ❑ Clay Loam❑ t Hardpan ❑ Adobe❑ Fill Material ------------ !fes Y , 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'[ l Y Size----------------------------------- ----- Liquid Depth --------- ---------------- Capacity -------------------- Type -------------------- Material-------------- ------- No. Compartments --------------•---- i --- Distance to nearest;.Well Well ------------ - --------Foundation --------------.------- Prop. Line ------------------..._ k J� LEACHING LINE "!`j 9 { ] 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 ❑ Water Table Depth ------------- ----------- ----.--Rock Size Distance to nearest: Well --------------__________________________Foundation -------------------- Prop. Line ---------------••----- REPAIR/ADDITION(Prey. Sanitation Permit# ---------------------------------------------------- - -------- - Date -------------•-------------------1 Septic Tank (Specify Requirements) ___________________ -------------------------- -------------- --- -- _ Disposal Field (Specify Requirements) _____�!�,c -t.�_-_-_- _-_ --_g�/ i �----------•-- •moi cl - - ---------------------- ------------------------ -------------------- - ---- -- ____ ____ (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. Nome owner or licen- sed agents signature certifies the following: "1 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 la of California." Signed ---------------------- Owner p,. ------ -------- ---------- - - -- BY ------------------------ - Title -��-On (If other than owner] FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY~_.. _--___'__�_ - ---------------- --------------------. DATE -- //--..30-_ 7l BUILDING PERMIT ISSUED ---- - ADDITIONALCOMMENTS ------------------------ -------------------------------------------------------------=--------------DATE ------- ---------------- --------- -------------------------------------------------------------------------------------------------------------- ----------------------------------:--------- -------------------------------------------•------------ Final Inspection b - _ ___-_-- p Y = - ---- - --------- ---------------••-------------- ------ ----------------.Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M