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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No: -__9..�� -- . -- ------- ---- ----------- ----------------- Date Issued _-_��-__�`�__�-�o --------------------------------------------------------- This Permit Expires 1 Year From 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 co fiance with County i once No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION - w - "--------------CENSUS TRACT -------------------------- = Phone ------------------------- :�6 Owner's Name Address -------------------- -- ---- + City - ` ------------------------------------ Contractor's Name _____ ______ ____ � _ .__.License #lZf 3 Phone __--.__-______.__.._____.____- Installation will serve: Residence partment House❑ Commercial ❑Trailer Court ,❑ I Motel ❑Other --------l!------------------------------------ Number of living units:_------!__._ Number of bedrooms ----i------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 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 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size_____________________________________----------- Liquid Depth Capacity -- Type -------------------- Material---------------------- No. Compartments ------------------•--- 0 Distance to nearest: Well ---- ft - - -- --- •-----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 0 Water Table Depth ------------------------------------------------Rock Size ------------ ------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date ------------------_---------------) Septic Tank (Specify Requirements( ---------------------------------------------------------------------------------------------------------------..-------- Dis osal Field (Specify Requirements) ------------------r----------------------------------------___-_k;6_1 - ---- --------------------- ------------------------------ -------- , -------- ----------------- -to "`(Draw existing and required addon 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 sub)e o Workman's Compensation laws of California." Signed ---- ------------------------ ----- --- -- ----- ---------------------- Owner pp _ BY --------- ------------- --------- ----- Title ------C'r` r+� (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- ----------------------------------------------------------- -- Z-- - - -- - - - - DATE ---.------------------- ----�- �- --- BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE -------------------------------- ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------------------- --------------------=-------------------------- -----------------------------------------------•-------------------------------------------------------- ----------------------------------------------------------------------------I------------------- ------------- --- -- ------I -------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------- -------------------------------------------- ----- -- - ---------------------------------------------------------------------------------- - ----- ----------------- jFinal Inspection by: _-__-- - Date -- ----' ------- -- ------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M