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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT F. --------------------------------------------------------- _ {Complete in Triplicate) Permit No. ------------------- -- ------ -------------------------- ________________________________________________________ This Permit Expires >F Year From Date Issued Date issued __Z[-_Z_7:-72,. Application is hereby made to the Joaquin Local Health District for a permit to construct and install the work herein . described. This-application is ma e`irt compliance wit ounty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION _. _ __ - - __ -.- f - :--- ._- 1- _ -- - ----/-��-- _ -.CENSUS 7RACfi_ ----------------------------- -- Owner's Name -------Phone •----•---•--. - .. Address ------------ ,.V__ - - --- --r3- S-------- City - -------- ----- Contractor's Name ------ -.- ------- ---- - ------- C ____-- s._.License # l� j �� 3- Phone -------------------------_---- Installation will serve: Residence M partment Nouse^❑ Commercial ❑Trailer Court ;❑ t rMotel ❑ Other --------r----�----------------- ---------------- I Number of living units------ ---- Number of bedrooms __J...Garbage Grinder ------------ Lot Size ------ _ _ ______________ -______ Water Supply: Public System and�name -------------------------------------------------------------- --------------------------------- ----------Private Character of soil to a depth of 3 feet: Sand'X Silt Clay ❑ Peat❑ Sandy Loam C7 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 26o feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid .Depth -------------------------- CapacitYI �C -------------------- TYpe -------------------- Material---------------------- No. Compartments ---- ---------- Distance`to nearest: Well `-----------------------------------Foundation ---------------------- Prop. Line ----------...:........ LEACHING LINE [ ] No. of Lines ------------------------ Length of each line ____ Total Length ----------------------------- 'D' -___.------.__-_.__._____-- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ____________________________________________ fi Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ______-___--_----_._.___ SEEPAGE PIT [ ] Depth _- ---------------- Diameter ---------------- Number - -------------------------- Rock Filled Yes ❑ No .❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest. Well ----------------------------------------Foundation -- ----------------- Prop. Line ---------------------- I REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------1 SepticTank (Specify Requirements) ---------------- ------------------------------------------------------------ -----------------•-------------------------------------- Disposal Field (Specify Requirements) ----- ________- -— —_____________________ A901 14 -- ClV V ------------ -----------------------µ (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 thi-,workrfor which this permit is issued, I shall not employ any person in such manner as to become subject to•Workman's Compensati.ori laws of California:" Signed ------- ---------------------:ter' --- ----- -------- _ _. _. ----------- Owner By ------------------------------------- _� . Title ------------------------------------- ------ ------ -------------------- (If other than owner FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -----: ------ -------------------------------------------------------- DATE d�� ------------- BUILDINGPERMIT ISSUED --------------------------- ------- ------------------------------------------------------------------ ---DATE - ---------------------------------------- ADDITIONAL COMMENTS --------------------------------------------------------- .._.. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------- ----------- ---------------------------------------- ---- ------ -------- - ---- Final Inspection by: - ---------- - ---- -- -------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M