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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----- -- --- -------------------- -------- - -- -------- (Complete in Triplicate) Permit No. -- --------------- 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 Na, 549 and existing Rules and Regulations: - .- - JOB ADDRESS/LOC N .,----CENSUS TRACT ----� ------------ Owner's Name --- - �- - ----- ----- --- ----------------------------- _ hone------------------------------------ _. _ l _41 Address .--__ _. r f -- ------ d. -._.. City Contractor's Name _._ -----------G ---------- __�/�,� ___.License # _/ y__ Phone ___________________________.__ Installation will serve: Residence ❑ Apartment Ho Commercial ❑Trailer Court ;❑ I iMotel ❑Other -- -- ---------------�-,' __ _-- . Number of living units:------------ Number of bedrooms ------------Garbage Grinder ------------ Lot Size -------------------------------------------- Water Supply: Public System and name -------------------------------•-------------------------------------------------------------------------------Privotp-f ` �1 Character of soil toga depth of 3 feet: Sand'j] Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loom.E] 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 200 feet,) r PACKAGE TREATMENT [ ] SEPTIC TANKf Size------------------------------------------------ Liquid Depth ----------------_--- Capacity ------------__ Ca acitY ----- ----- _--- _ Type ___________________ Materiar______.__________ No. Compartments _______--------_...... Distance o 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 --------------------•--------------------_._ 1 i Distance to nearest: Well _______________________ Foundation ------------------------ Property Line -_.-------............. . SEEPAGE PIT [ ] Depth _.__ __________ Diameter _______________ Number ____________________________ Rock Filled Yes ❑ No i❑ I Water Table Depth ------------------------------------------------Rock Size ---------------------- Distance to nearest: Well _______________________________________Foundations ___.----------j---- Prop. Line ---.____..____.__..... REPAIR/ADDITION(Prev. Sanitation Permit# --------________ _ - -------------------------- Date ----------------•----------------=} Septic Tank (Specify Requirements) ------------ ------------------------------------------------------------------------------ r sal Fie! (Specify Requireme -- ------- ------y` I _ ---- T ------ --- - -- --------- - - --- --- ---- ---------- - ^' (Draw existing and required a ition on reverse'side) 4 ' 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 liven• sed agents signafure certifies the following: s "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 orkman's Compensation laws of California." Signed - --------- - ---- -- -------------- ----- --- -- -- ----------------------------- Owner By ------------------------- - - . TitlA------ --� ---- ------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------------------- DATE --7 J---•0 -------------- BUILDING PERMIT ISSUED -------------------------------------------------------------------------------------------=--------------DATE ADDITIONALCOMMENTS -------------t---------------------------------------------------------------------------------------------------------- ------------------ - ------------------------------------------------------------------------------ -----------------------"----------------------------------------------------------------------------- i - ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- --- -------------------- ------ - -------------------------------------------------------------- ------- Final Inspection b -Date ---------------------- P Y SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M