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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------- ----------------------- (Complete in Triplicate) Permit No: ---- - ------------------- -------------------------------------------------------- - This Permit Expires"I Year From Date Issued 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 C ty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC TIO -= ------------------•- r ' � CENSUS TRACT -------------------------- tl- Owner's Name --d------------ -----.----------- -------- =F---- ---------Phone -------------------- •------- ---•-- Address _2 � �/ City --------- ;t Contractor's Name ------------------�F.License # 17_ .--$_` _ Phone ---------------------------. Installation will serve: Residence impartment House-❑ Commercial:❑Trailer Court Motel F-1Other ------------------- ----------------------- Number of living units:__________ Number of bedrooms _1_---------Garbage Grinder -,11.0____ Lot Size _ -______________ Water Supply: Public System and name == _ ------------------------------------- -----------------------------------Private []-~ Character of soil to a depth of 3 feet: Sand Silt❑ "day ❑' , Peat❑ Sandy Loam ❑ Clay Loam❑ Hardpan ❑ Adobe '❑ Fill Material ------ _ If yes,type ____________________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [g! SEPTIC TANK'[ ] Size----`$-- - _91------- _5--- _-- Liquid Depth ---4------------------ Capacity :1,Loo _ Type _�)�c_eC_ platerial___ _6o. Compartments r Distance to nearest: Well _______________________Foundation _14.____-__________ Prop. Line ________._:..__.______ LEACHING LINE [� No. of .Line's �------------ ------ Length of each line_lA2o_."..... ---------- Total Length /P?p__..___.___.___ ------- - - -- 'D' Box -7- 6----- Type Filter Material ---/?P:A---_Depth Filters Material __f�-_ _____________ ____ __ ____ __ Distance to nearest: Well ------------------------ Foundation _-- _ Property Line --_-- SEEPAGE PIT [ Depth ------- _______ Diameter _______________ Number --------------------\------- Rock Filled Yes '❑ No ❑ r Water Table Depth ------------------------------------ ------Rock-Size-- ------1\---------------------- iI Distance to nearest: WeiI ----------------------------------------Foundation ------------- Prop. Line _...-----_--_ ........ REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------- __________ Date ---------------------------------- -------------- - _ Septic Tank (Specify•Requiremehts) ------------.___ _-_ ; 3 _ ____.________________________________________________________ w,y . v bisposaf'Field (Specify Requirements) -------`---�------ -----------.-------- ------------- _ } ----------------------------------------- -- = i F,¢ _ ri ______________________________________________________ ------- ---___ _- __-_______ ----- ----_-____ ------_-_ ______-_______ ___ _____-______-__ __ ____- (Draw existing and required addition on re"verse side) I hereby certify that I have prepared this application and that the wofk-.will be done-in 'accordance with San Joaquin County Ordinances, State laws, and Rules and Regulations of the S nrJoaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "1 certify that in the performance of the work'for-which-this`p-ermit-is"issired,=V-shall,not en+p1ay any person in such manner as to become subject t Workman C mpens tion laws of California." i . Signed -------------------- ------------- --- ` Owner By ------------------------------------------------------------------------------------------------------- Title ------------------------------------------------------------------------ (If other than owner) FOR .DEPA IE USE NLY APPLICATION ACCEPTED BY ------------------- - DATE i I BUILDINGPERMIT ISSUED -------------------------------------------===='----- --- ----- --------------------------- --------------DATE -------- ----•------•------------------•-- ' ADD1TlONALCOMMENTS - =--------------------------------------------------------------------------------------- --------------------------- r = -----------------------------•----•--- Z ---------------------------------------------- __ __ -------------------- ____ _ � - - --- -- -_ Final Inspection by: -------- `' 't- -- `--------------------------------------------------- ------------Date - l_- SAN JOAQUIN LOCAL HEALTH DISTRICT �� E. H. 9 1-'68 Rev.`5M. �,j\ hw�•••�. `� .'.�. !� -• ___ ,,,o-�...r _ -_�.....T_._,.._ _ _ _.. �