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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ -/------ ----------- --------- ------- u (Complete in Triplicate) Permit 14Jo. --------------------------------- ----------------------- XV, This Permit Expires 1 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: JOB ADDRESS/LOCATION .-------- ---------I ------------------CENSUS TRACT ------------------- Owner's Name ------ ---1--------- -- - -- - --- -------- -- ---------------------------------- -------Phone Address ------------------------------------ ----- - ----------------- City ------------------,----/-------------------------- Contractor's Name -..-------------- ---------------------------:______.License # ___.______________ Phone Z-66_JNO Installation will serve: Residence ❑Apartment House❑ Commercial:OTrailer Court i❑ Motel ❑Other -------------------------------------------- Number of living units:----- Number of bedrooms -----_5---Garbage Grinder ------------ Lot Size -------------------------------------------- J 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) S" PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depth __-__________--__ ...... ? 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 --------------------........................ 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. Sanitation Permit# ____________________________________________ Date --------------.-_..-___-__________) r Septic Tank (Specify Requirements) --------------------------------------- --- --- -------------- ----- ------ --- --,P--------------------------- Disposal Field (Specify Requirements) ------- --- ---- ----------------------- --- ----------------------- ---- -4-------- --------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 to Workman's Compensation laws of California." Signed ------------------ ------ --- '- ------•----------------------- ------ Owner BY ' Title - - = -------------------------- ------------ (if of r han owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- + --------------------- ----------------------------- ------ DATE --- --------------- BUILDING PERMIT ISSUED ------------- ------------------- X--- - ----DA E ------------------------------------------- ADDITIONAL COMMENTS ----- --------31 K_�3w 1_- -GQ- _4vx- ----------------------- -- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------- -------------------------- ----------------------------------- ----------------------------------- ------------------------- ----- ----- - ------=------- Final Inspection bY - ----- - - --------- -- - ------------------Date ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1 E. H. 9 1-'68 Rev. 5M