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EOR OFFICE USE: APPLICATION FOR. SANITATION PERMIT -------------- --------------------------- Permit No. _ (Complete in Triplicate) I - >� _ Date Issued - This permit Expires 1 Year From Date Issued ----------- --------Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ' 4 ccqq fZeA141_e-1l....1_1!� -----------------CENSUS TRACT --- ---------t _--- JOB ADDRESS/LOC _ N .------�- -�=--=j-- - Owner's Name b- �&q-b fZl -L__ -PhonecV__=_.a L_ ------------------- - Address -------- --------------- -------------------------------------- --------------------- City f�_�+ ---- C'� �/� Contractor's Name . - - License # 3 /�Phone '•�� Installation will serve: Residence ErApartment House❑ Commercial :❑Trailer Court ',❑ / Motel r7 Other ------------------------------ ------------- Number of living units:___!-_---- Number of bedrooms _�------Garbage Grinder ------------ Lot Size __ ---------•---- Water Supply: Public System and name --------------------------------- -----------------------------------------------------•---------------------Private Character of soil to a depth of 3 feet: Sand Sift❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ HardpanX Adobe'❑ Fill Material ------------ If_ye ----------_____ (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 I ] SEPTIC TANK f ] Size_____________________ _._- ---------- Liquid Depth ____-____.__._-------.-.--- Capacity ------------------- TYPe ------- Materia --------� ------------ No. Compartments ---------•------------ Distance to nearest: Well -_-.- ------------------------- ----•Foundation ---------------------- Prop. Line -----_-- ••----- LEACHING LINE [ ] No. of Lines _______________________ ngth of.ea line-------____.----_____------- Total Length _____--_________------------ 'D' Box ------------ Type Filter terial ___________ ________Depth Filter Material ____--_________---------------------------- Distance to nearest: Well ____ ___________________ F ndation ____-_____.____-__-__-- Property Line ----------------........ F SEEPAGE PIT [ Depth -------------------- Diam er ---------------- umber ---------------------------- Rock Filled Yes ❑ No I❑ WaterTable Depth -------- --------------------------- -------- --Rock Size --------------•----------•------ Distance to nearest: We _ __ __________Foundation -------------------- Prop. Line ---------._______-_- REPAIR/ADDITION(Prev. Sanitation Permit# _______-.-_-------------------- ------------ Date ___________-----------•----------) t ---------------- Septic Tank (Specify Requirements) ---- -------- ----------•---------- ----------------------- ---------------------------- -----•.-•---------- Disposal Field (Specify Requirements) --------------------------------------------------------------------------------------------------------------------- {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 t Work n's Compensation laws of California." Signed ------ - --- ----- - -r------ - ��----gg--�---- ---/-- - ---` ------------------------- - Owner - ---- ---------------- �--BY - Title ---- - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------ -------------------------------------------------------------- . DATE BUILDINGPERMIT ISSUED -----------------------------------------------------------------------.-----------------------------------DATE ------------- ------------------------ ADDITIONALCOMMENTS ------------- ---------- ----------------------------------------------------------------------------------- ------------------------=----------------------- ----- ------ ---------- ------------ ---------- --------- - --------------- ---------------- --- ---------------- --- ---- -�. �� ----- --- -- -- Final Inspection ---- ---- -- -- - ----- r ------Date ' SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M �