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FOR OFFICE USE: APPLICATION FOR 6ANITATION PERMIT __ Permit No.. _. `-- - "'► (Complete in Triplicate) _-7-/S ----------- This Permit Expires ] 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: ) JCENSUS TRACT JOB ADDRESS/LOCA ON _-__.-��,-- -`-''--- � ___ jjj��` ___----------- ----- ------------ Phone Owner's Name __-- - yo � ! v ---- City ---------------------------------------- ---------------------- Contractor's Name --------- ---------- --�------ -------- - ------------- ------------ --- ------License # ------------------------ Phone •--------- Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑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'❑ Silt❑ Gay .❑ Peat ❑ Sandy Loam -❑ Clay Loam.0 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,) SEPTIC TANK Size = -------- Liquid Depth --------------------------- PACKAGE TREATMENT [ I [ o Capacity-- TYpe ' aterial---------------------- No. Compartments ---�---•------_---- N Distance to nearest—Well ------------------------------------F undafiion _______-------------- Prop. Line ------- ---=•------- LEACHING LINE [ ] No. of Lir es -_____-------- Length of each liJp_ --------------- Total Length ,___1.�-------------- ---De ------------ --------•- Depth Filter Material --------------------- ! 'D' Box _________-- Type Filter Material _________________ p I -------- Foundation --------------------- Property Line, Distance to nearest: Well _______________ """"""""-"'-------•-•••� 1 __ Rock Filled Yes No i❑ SEEPAGE PIT [ ] Depth --- --- ----------- Diameter Number WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ---------------------------_------------Foundation ---------------- Prop. Line ..---- REPAIR/ADDITION rev. Sanitation Permit# -------------------------------------------- Date ___ __ __ -------) - o-, --t -.--- - - Se tic Specify Requirements) _ Q Disposal Field (Specify Requirements) k- -sot ------------------------------------------------------------------------------------------------- ----------- ------------------------------- --------------- ------------------------- �r (Draw existing and_required addition on reverse si d e W I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin C County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. biome owner of icen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner � as to b. c me sub et o ®rkmanls ation laws of California." Signe ---------------------------------- Ow Owner -------------------------------------- --- ------------------------------. By -- - ----------------------------------------- Title (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- ------- ---------- -- -------- -- ----------------------------------------- DATE --------- ------------------ BUILDING PERMIT ISSUED -------- I-------------- -- ------------ ------------ DAT - ----------- ADDITIONALCOMMENTS ------------- -------------------------------•-------------•-----•- -- ---------•---------------------------- -- ---------- --- ---=------------------------------------------ ----------------- ---------------------------------------------------- -- -- t 1 -- - ------ - te ----- ------ Final Inspection by; a - SAN JOAQUIN LOCAE• HEALTH DISTRICT ` E. H. 9 1-'68 Rev. 5M.