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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT / r� {Complete in Triplicate] Permit No. -3t --------------------------------------------------------- --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date issued r/ - Application is hereby made to the San Joaquin Local Health District for a per 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 AbbRESS/LOCATI N �( .S I---__--G: c- .2 ------------------------ --------------------------- --CENSUS TRACT --------------- .......... Owner's Name - ----- -e - -------------•------------------- Phone -------------- -•--- Address �� c- ----- r - ----•--- City ----- —' ------------------------------------ -- =------- -- ----------------- ------ - - - Contractor's Name -----------F /� _C ----------.License # - ` Phone ---------------------•- Installation will serve: Residence [t Apartment House❑ Commerciat ❑Trailer Court ',❑ Motel ❑Other -------------------------------------------- Number of living units--------ar--- Number of bedrooms _�!------Garbage Grinder -------- --- Lot Size __________________________________-_--____ Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------Private [� Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loamr 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 200 feet,) Q PACKAGE TREATMENT j ] SEPTIC TANK [ ] 4 Size------------------------.---------------. ------ Liquid Depth __._-- -----__---________- Capacity --- ---------- Type _ -' ..Material---------------------- No. Compartments ----------------- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------- LEACHING LINE [ ] No. of Lines ----- ------------------ Length of eachIihe-------------_-------------- Total Length _-_-_______-_______.__..__.. 'D' Box ____--_-.._ Type Filter Material ---------------'----Depth f=ilter 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 -----------.--......._ REPAIR/ADDITION(Prev. Sanitation Permit+ --------------_ _,__,__,__,.__----____-__ Date ----------------------------------I Septic Tank (Specify Requirements) Disposal Field (Specify Requirements) ---------•_•---------------•--- ----------------------------------------------------------------------------------------------------- -� , - .- --- -- -� -- ---- ------ --- - ---- - ----- /�--�®- -----�- -- ------ --- -- (Draw existing and required ddition on reverse side) I hereby certify that I have prepared' this application and that the work will be done in accordance with Son 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 ------ ---- 2� - - --------------- - - -------------- Title --- --------------------------------- (if _ -- -- - -- --- ----------- -------------------------- - - (If other than owner) FOR .DEPARTMENT USE ONLY w F --------------- ------------- DATE -a_.-'._` APPLICATION ACCEPTED BY - - - -- -- -- - - -- --- ------------- ---- ------- - - - BUILDING PERMIT ISSUED -------------------------- -------------------------------------DATE -------------------------------------- �--- ADDITIONALCOMMENTS .------------------------------------------------------------•---------- ---- ------------------------------------ ------------ - --------------------------- ---------------------- ----------------------------------------------------------------------------------- -- ------------------------------- R - �� ------- -------------------------------------- ---------------------------- ------ ---- Final Inspection by: bate ----_---_--__---.----'_- -..__._--- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M