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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------- Permit No. -Z=3 - ---------- ----- --- - -------------------- (Complete in Triplicate) ------------------------ This Permit Expires 1 Year From Date Issued Date Issued ___ _-_�✓_:_71/ 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: CENSUS TRACT __-----``-_--------------- JOB ADDRESS/LOCATION ��--- �------------ Owner's Name ------- - /`- yrs .l---------------------------------------------------------Phone ------------------------------------ i Address -- _ -.__ ,/ �/ --------------- cityd 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 __ei�__ 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 RI 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.) Ilk NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) SEPTIC TANK S�i ?r�0PACKAGE TREATMENT , _ ______________________ Liquid Depth - -_._..__-.________- Capacityf-a1 _ Type Material No. Compartments ___ __-•---__-- Distance to nearest: Well _________.e49 _____________Foundation _________ Prop. Line ------- LEACHING LINE r No. of Lines ----�-------------- Length of each line ,-�___.-.-___ Total Length �..r -�• _ 'D' Box _ Type Filter Materia� //_Ll_-Depth Filter Material ------------------------------------ Distance to nearest: Well ----�, ------------- Foundation _ ------------- Property Line/_/ew............ SEEPAGE PIT (j Depth A- /----- Diameter s1��-- Number .__ ----------------- Rock Rock Filled Yes j No i❑ r� ,r Water Table Depth ------.. Rock Size/----:? Distance to nearest: Well ____ _____--------------Foundation ---- Prop. Line .. .- ____-_-_-__ REPAIR/ADDITION(Prev. Sanitation Permit# ________ ___________________________________ Date -------------.--------------------) SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------------- -------------------------------------- Disposal Field (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: "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 than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- - - --------------- ----------------. DATE _ _ _ 6.~7_ -------------- - --------------------------------------------- BUILDING PERMIT ISSUED - --------------------------------------------------- -------------------- -----------DATE ------------------------------------------- ADDITIONALCOMMENTS -------------------------- --- -------------------- --------------- --------------------------- -------------------------•---------------- ----------------•--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------ ----------------------------- - ------- - - - - ------ Fi ---------- ection bY= ---___-Date ------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M