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IbR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------- Permit No. ----------- - This Permit Expires 1 Year From Date Issued(Complete in Triplicate) 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 witp County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC TIdN .__ _�� _,____ �' , 9/.�j ------CENSUS TRACT _______________________ ------------------------- -- --- Owner's Name '--- 'gam � r-------------- --- - - -Phone Address _____-_ -3=J,_ __ ,� -�f .at.�i City s �-- ° '------------- _...--..License # ��7�--- Phone Contractor's Name�.��.. ?-�--- - --------------- Y Installation will serve: ResidenceoApartment 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❑ Clay ❑ 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.) U, NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size----------------------------.------.------------ Liquid Depth -------------------------- N Capacity -------------------- Type -------------------- Material--------------------- No. Compartments _.-------------------- Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ...................... LEACHING LINE [ ] No. of Lines ______________________ Length of each line---------------------------- Total Length ----------- ................ 'D' Box ------------ Type Filter Material ____________________Depth Filter Material --------------------I....................... Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line -----------------..-.-__ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes '❑ No 0 Water Table Depth ---------------------------------------- -------Rock Size -------------------------.---- Distance to nearest: Well -____________________________________Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. $anitation Permit# ____________________________________________ Date ______-____________---__-...______) Septic Tank (Specify),Requirements) ----------------- ------------------------------------ ------ --- -- -------------------------- Disposal Field (Specify Requirements) _ ------ . �-----7°_ -� ------•-- t ---------- -------- ----------- ----------------- --------------------------------------------------------------------------------------------------------------------------------------------- (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, 1 shall not employ any person in such manner as to be% e s .ject to ork 's Compens n laws of California." Signed ------ - --- ------ ----- CGc�� ------------- Owner - ------ ---- - BY #--- ------- Title - - (If other than owner► oa OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - -----------------•----------------------------------------• DATE ---- --- _7=---7 2-------•- BUILDING PERMIT ISSUED -_-_ __ ______-___________________________-_DATE -------------_----------------------------- ADDITIONAL _______ _ADDITIONAL COMMENTS ______-__ _ *_- ____-_ _,* _ L_ _ - - �,. ----- '-- ------------------------------------------------------------------- --- ------------ -- ----------------------------------------- -------- --- ----------------------------- ----------------------------------------------------------------------------------------------®--------r- � ------------------------- ------------------- ----- �Final Inspection by: . -- - - - -------- ------------------------------------------------------------ - Date - ---- -------- ---------='----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M