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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------- 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 compli Ice w' h County Ordinance No. 549 and existing Rules and Regulations: J I ADDRESS/LOCATi / ----IPS '.?W. ENSUS TRACT -------------------------- JOB' - ---------' �f Owner's Name - - ------- -------Phone --------------------- Address --- �� ------•-_. City ----`-- Contractor's Name _ `_____.License # .� ---- ___ Phone �f�__5_31Z __:�__ Installation will serve: Resi nce (r, Apartment House❑ Commercial :❑Trailer Court ;❑ Motel ❑ Other -----------------------------------•-------- ,�,'} j Number of living units_____________ Number of bedrooms ______Garbage Grinder _'d----- Lot Size ---1�a_V_- Water Supply: Public System and name ---------------------------------------------- --------------------------------------- ------- ----------- ---Private ] Character of soil to a depth of 3 feet: Sand'❑ Sift❑ 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 204 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size-------------------•---------------.------ ----- Liquid Depth -------------------------- Capacity -------------------- Type -------------------- Material--- ---- No. Compartments -------- ............. v Distance to nearest: Well ____________________________________Foundation ----------------------- Prop. Line ---.___________.______ LEACHING LINE [ j 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 ❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------------._--_.-- REPAIRfADD-lTION(Prey. Sanitation Permit# .......... f------------- ) Date ____ ___-.______-__._._.___ ______ rSeptic Tank (Specify Requirements) ----------- ,p Field (Se ' y Requirements) _______ ___ _ __ _ __________ c.x------------------------------------------------------------------------------------- ---------------------------------------------------------- --------------------------------------- -- ------------ - (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 -------- - - -------��/�ZIr ---------- -------- ---- --------------- Title ----- , (If other than o er FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - -- I ----------------------------------------------------------------------------- DATE -----6-- ---------------- BUILDINGPERMIT ISSUED --------------------------------------------•-------------------------------------------------------------DATE ------------- ----------------------------- ADDITIONALCOMMENTS ---------- -- --------------------------------- ---------------------------------------------------------------------------------.:---------------•----------- --------L=---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------- ------------------------------------------------------ ----- - - ------- ----------- -- - - Final Inspection by: -----------------4 - ---------------------------------------- --------------------.Date ---�-1l---------------- 1----------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M