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t. FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ "----------•------ Permit No. _7 Z- 6 .. . n (Complete in Triplicate) L Date Issued --------------------------------------------------------- Tis Permit Expires 1 Year From 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/LOCATIO --------- ---- --------------------------------------CENSUS TRACT ----------•---.-----..-_.- Owner's Name ---% --�--------- --------------------------------------------- -------------------Phone ��'�'--.1.1. Address --------- - -------------------------------------------------------- city --------------------------------- Contractor's Name ------- ex ------------------License # .*J Phone � . Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other -------------------------------------------- rNumber 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) e / i e PACKAGE TREATMENT SEPTIC TANK Size__________ .�e _ .�� Liquid Depth _____'_---_____- Capacity, _0 ___-_ Type .,420--f_ __ MaterialF�Foundation __ No. Compartments .................:...� P Distance to nearest: Well --_-----_ - '� �PQ_____�_ p. Line -...__ I�.. _ 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 i❑ Water Table Depth - ----------------------------------Rock Size ----------------------I-------- Distance to nearest: Well --------_---------------------------....Foundation _____________--__-''Prop. Line _..._... ............. REPAIR/ADDITION(Prev. Sanitation Permit'- -------------------------------------------- Date __ _ ---------------- - -------- �- =-------- Septic Tank (Specify Requirements) ------------------,,log DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------=----------------------- ----------------------------------------- ---------------------------- ------------ ----------------=--------- - --- (Draw existing and required addition on reverse side) 1 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 d BY Title ----- - (If other than owner) r F EPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- ------ �( -- . DATE --- ---ao-- z---------------------- BUILDING PERMIT ISSUED ------------------------- -------DATE ------------ --- --- --- - - - - ADDITIONALCOMMENTS ------- -- - -- ---- ----- ----- - ---------------------------------------- ----------------------------------------------------------------------- -------------------------------------------- - ------ --- - -------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------- ------------------------------------ -------- ---------------------------------------------------- -r� -------- ------ =---- -- Final Inspection by: ----- - ------------------------- -----------------------------------------------------Date ----- _��- -------- N JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M