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{ FOR OFFICE USE: .J� APPLICATION FOR SANITATION PERMIT ,f ---------------------------------------- (Complete in Triplicate) Permit No: -------------____________----.--__________---__ This Permit Expires 1 Year From Date Issued IN Date Issued -- -'-[- --7-- --- 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/LOC -----------------CENSUS TRACT -------------------------- Owner's Name -- ---- - -- ----- -----•- -----------Phone -------------------------------------- ------ ---------------------- Address - ----- =�' Cit --- ------ Y - -----o�-'-/_�------------- Contractor's Name 6•---- r -,---.License #/_ �Phone --------------- -------- lnstallation will serve: Residence Apartment House(([] Commercial: Trailer Court in ( Motel ❑Other ------------ Number of living units:___ _____ Number of bedrooms ------Garbage Grinder __________ Lot Size ---_--- --~ __________-__________. Water Supply: Public System and name ----------------------------------- -------- ------------- --------------------------------------------------Private [� Character of soil to a depth of 3 feet: Sand'❑ ilt ElClay F] Peat E] Sandy Loam ❑ Clay Loam [] i - # r 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: i{Nolseptic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ I s SEPTIC TANK.[ ] Size Liquid Depth /A capacity -------------------- Type -------------------- Material---------------------- No. Compartments .----.-----------: Distance to nearest. Well ------------------------------------Foundation ---------------------- Prop. Line ----------:__--.-_.--- i � ` F - 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 ❑ F IWater Table Depth --------------------------------------- ----Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line __-_-___.-____-..-._.. REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) --------,-------------------------------------------------------------------------------------------------------------------------------- Disposal Field (Specify Requirements) --- ------ 13 X-��--------------------------------- -- ------------------------ E . ---------------------------------------------------------- (Draw existing and required.addition on reverse side) r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin i County Ordinances, State Laws, and Rulesand'Reguldt'ions 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 Hermit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed �_ _().RV T �` ` Owner BY ------- Title --------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY aa APPLICATION ACCEPTED BY . -- -- - ---------------------------------------------- ------------- DATES-f- 7l----------------------- BUILDINGPERMIT ISSUED --- -----------------------------------------------------------------------------------------------------DATE ------------------------------------------- ADDITIONAL COMMENTS -------------- ----------------- - -------------------------------------------------------- --------------------- ----------------------------------------------------------------------------------- ` Final Inspection by: � ---------- ------------------------- - f ---------------------------------------- ----------------------------- -Date .'�-- -/ ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M