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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT q Permit No= ---------------------" (Complete in Triplicate) -- --- --------------------- 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 .ZCP �_ - --------S-- 0- --------/9f- 04- '- t"-k�Y_---------CENSUS TRACT ..... Owner's Name l ---------Phone ---------=-------- ----------_---- - Address ----------------- City 'k Contractor's Name - L= 1 f`y { License # tf----- Phone Installation will serve: Residence ®Apartment House❑ Commercial ❑Trailer Court s❑ Motel E]Other---- ----------------------------- Number of living units:_-__ -_ Number of bedroo s r-- ----(--- Garbage Grinder - lot Size --1 �Z ------- Water Supply: Public System and name --------------- ----•--------------------------------------------------------------------------------------__Private Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat Q Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe'❑ Fill Material __/V S�__ 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 seepa a pit permitted if public sewer is available within 200-feet) PACKAGE TREATMENT [ ] SEPTIC TANK; Size---___ _- -_-- Liquid Depth .- �.. ------------ Capacity _/_�0--_ Type __ 0--` aterial-f-71C No. Compartments - '-..---...- �istance to nearest: Well _-_6�-----------------------Foundation _---j__-ey___ ...... Prop. Line ....5_-.___f__.....-- LEACHING LINE (A No. of Lines -----I--___--_-____ Length of each//line----- Total Length ._/.�xL------------- 'D' Box --_-_____-- Type Filter Material /Z-CA—Depth Filter Material J?*.......-............-.......... Distance to nearest: Well ----6-V------------ Foundation __I�-------------- 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 ----------------------------------) Septic Tank (Specify Requirements) -------------------•----- ------ - DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- (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: "1 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 become subject to Workman's Compensation laws of California." Signed ---- -------- -- --- -------------------- ------- --------------------- Owner ----- - - \ = ,�i�' ---------------------- Title -------- -------------- ------------------------------------------------ By (If other than owne FOR DEPARTMENT USE ONLY 7 /�/_A-L__D-_---_- APPLICATION ACCEPTED BY-------- --�--�--Q'- - ----------------------------------------------------------. DATE ---- - ''r------- - ----------- BUILDINGPERMIT ISSUED -------------- ---------------------------------------------- ---------------------------=--------------DATE ----------t ADDITIONAL COMMENTS ----------------- - ------------------------------------------------------------------------------------ ------------------------ ----------------------------------- ---------- ----------------------- -- - -------- ------ -- --------------------------------------- -- ------------------------------------------------- - Final In ection by: /� -A--7 ------- Date �� SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M