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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �� Permit No. ------------------ ------------------- ----------------- (Complete in Triplicate) ---- -------- - Date Issued ---------------- - - r - ------ -------------- 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 comDlian ith County _Orinance No. 549 and existing Rules a��egulations: 23�d�I �2 JOB ADDRESS/LOCATION" �. �--- - -- -�-'��-`-{�--�-AAI��CE SUS TRACT _.___-"----- -.-----•----- _ ." Phone --- •---- - --- Owner's Name - ' �y - Address .._ - --f-- --- ---- - --- ------- - -- - - -------- ------------- city—,Contractor's Name License # Phone Installation will serve: �esidence [Apartment House❑ Commercial ❑Trailer Court '❑ Motel ❑ Other ------------------"-- ----------------------- Number of living units:- G-"--"- Number of bedrooms --_ --_.Garbage Grinder ------------ Lot Size -- ------------- Q�.. Water Supply: Public System and name --------------------------- ------ ------ •--- ------------------------------------------- - "- " -"-- -------- ------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt Clay El p----- eat 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.) p NEW INSTALLATION: (No septic tank or seepage pit permitted 3if publics eswer is available within 200 feet,) fV - r- PACKAGE TREATMENT [ ] SEPTIC TANK [l< Size_V-14 1_X_q_I --.S'--------------------- - Liquid Depth Al-------------;- y Capacity � ✓ ----- TYpe ` '`t-- Material_' -' No. Compartments __- --. ~'e' _------------Foundation -Lo- ..-------- Prop. Lirie -.� .±------------•" Distance to nearest: Wel! ___--____-"_ o i ----- _"-- Length of each line---------jA-a- - -- ------ Total Length _. aea------------------ LEACHING LINE [ Jd` No. of Lines ___- -- _ �, D' Box __t Type Filter Material ------Depth Filter Mate rial,-_/,f------- Imo✓ Pro a Line. ------------------ --- kDistance to nearest: Well ------------------------ Foundation __-------- p SEEPAGE PIT [ ] Depth -------------------- Diameter --_-----------_ �Number --------- ------------- .Rock Filled Yes 0 No Water Table Depth -------------------------------------------- -- Rock Sze ----------------I-------------- Distance to nearest: Well -------------------- ---------------------Foundation ------------ -:---- Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# "---------- ------------------------------------------------------- Date ------------------------ -----) ------------- Septic Tank (Specify Requirements) _�. ^=`.-,--- - «-_- R Disposal Field (Specify Requirements) ---------------------- --------- - ------------------------- -------- --------;- - 4. -- - - - -- ------- -- ------------- - --•----- -------- ----- ---------- (Draw existing and required acJdition on reverse s� e I hereby certify that I have prepared this application and that thevwork will be done in .accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the. San Joaqusn Local Health District. home owner or licen- sed agents signature certifies the following:-- , - - "I certify IDA" in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to bec a subject to Workman's Compensation laws of California." Signed . r' -------------------- Owner A ---- -- ----------------- -------- - ------- -- ------------ ------------- -:yT�itle -------- ------------------------------------ (If other than owner) —F,0111-DEPARTMENT. USE. ONLY._ -# APPLICATION ACCEPTED BY .- ------ ----------------------------------- DATE --- BUILDING -BUILDING PERMIT ISSUED -- - --------- ----------- --------- ---------- --------- ------- ----------- --------------DATE ------------------------------------------- ADDiTIONAL COMMENTS ----------------------------- -------------------------------------------------------_ .,. .�.. _ _ . w . r . ,_ _ .. . -------------- ------------- ------------------------------ ---- - at- - -/--- ----- Final Inspection by: .,. . -_ __ ------------------------------=--- ----- - ---- - Date �." SAN- JOAQUIN LOCAL HEALTH DISTRICT K . E. H. 9. 1-'68 Rev. 5M _