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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: ._-_-"""""-- -------- -------------------------------------- +nom (Complete in Triplicate) --------------------- --------- --------------------------- Date Issued . :_ s -la� This 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/LOCATION -- -------- --- - --------CENSUS TRACT --------------•--------- - Owner's Name ._ ------------------------------ -- -------------- Phone j - ---- "- Cit Address .... " ! .- ----------- ry --- _ Y ,�.., H� ' License # � Phone�------= '------------- Contractor's ------•==-=-Contractor s' ame -____._ __._ __-_ � -"-- �:' Installation will serve: Residence M Apartment House❑ Commercial❑Trailer Court 0 Motel ❑Other _---------=- `-------- , ' I Number of badraomst Number of living units:...... Garbage Grinder ------------ Lot Size I Water Supply: Public System and(name -------------------- -- --------------------_-- ---------------------------------- ---------- ----------- --- Private [ 'J Character of soil to a depth of 3 feet: Sand'❑ Silt Y Clay'❑ Peat❑ SandyLoom ❑ Clay Loam ;❑ Hardpan [ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- (Plot plan, showing size of lot,,locotion of system in-relation to wells; buildings, etc. must be placed on reverse side.) C j NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ Size__ _ - --- -- -------- Liquid Depth .---------------.-- ) ©Q -�� Materia[_-�-�''*-� No. Compartments .2— Capacity�_.��-------lWell TYpe --- ---- -- - - «f F -4 Distance: to neares _____________ �3------- ------•Foundation _._f Q__--------- Prop. Line ____�_. --.-.-- LEACHING LINE [f No. of Lines ------- ------- Length of each line----1-ULA- ------- Total Length -17 -P-5? Type Filter Material P ------------ --------- ----------- i ron, "- -- +- "-- ,____De Depth Filter Material J-17--------------------- 0,-- f- ---------- Distance arest: Well ---__s 5o_1--------- Foundation .___J,_V--------- ---- Property Line - ""_- ` • - SEEPAGE PIT [� Depth = S'------- Diameter -- --------------- Numbe;,V,'-------• _---_-"-«- Rock�Filled Yes No ❑ Water Table Depth Rock Size _.. �-. o ---------- --- pU-r---•------ Foundation ----t a----------- Prop. Line Distance to nearest: Well ______________� REPAIR/ADDITION(Prev. Sanitatib n Permit�# -__----.�--- � Ddte -----�------------------- 1 I ,.-.—d - --------- ----------- --------- Septic Tank (Specify Requirements) ---- ------------------------------------------------------- Disposal Field (Specify Requi�rements)-- ----------------------------•------------------------E--------- ------------ ; ----------------------------- . 'f , a ______________ _ _ _____________________________----- ---------------------- ------- _ ______________________ _______________, ._______--________________-.. ___ ..._____ __________________________ ___________ _______________ - - _____-_______ ______-___-+____________--_____________ -____-___ _ __.__ • _______-------_------------------------------------___ ___ ___________________________ ___________ __-_--. . (Draw existing and required addition on reverse side) tl 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: R "I certify at in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner aqnee co a subject t Workman's Compensation laws of California." S -------------------•- owner- - ------- - -- --- ---- -- ------------------------------------- - B Title -------- ------r------------------------- --------------------------------- --------------------------- ------ - (If other #h n owne FOR DEPARTMENT USE ONLY g APPLICATION ACCEPTED BY _ - -- -- ----- -- --- --------------- ------ - ---------DATE - ---------- ---------- ---- -- ----- DATE -.= . BUILDING PERMIT ISSUED ---------------------------------------- ----------------- -- ---------------------------- =-- ADDITIONALCOMMENTS --------!------------------ ------------------------ ------------ ----- ------------------- ----------------------------------------------------=------------------------------------------------------- -------- ---------------------- ----- - -- ---- ' ----------------- ------------------------------------ ------- ----------- - -- Date �� --- ----------- Final Inspection by. _ __ ___ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M