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FOR OFFICE USE: !d �; APPLICATION FOR SANITATION PERMIT" V (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 y Ordinance N 54 and existing Rules and Regulations. _ 7 -_--- _ ---- __r-_-._--••----•- JOB ADDRESS/LOCATION __________ _-__.._ _ _/_CENSUS TRACT Owner's Named-- --------- Phone Address --------- Q . - ity ------------------------- Confiractor's Nam --- - License #/f .��_"Y_ one � --------------- Installation f Installation will serve. Residence partment House❑ Commercial :❑Trailer Court ;0 fMotel ❑Other -------------------------------------------- Number of living units:-------- Number ofr ours _Ga ba Gr' der Lot Size 15--- ____________ _ Water Supply: Public System and name ------ -1----- � '- ----- -------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ .!Silt❑ Clay ❑ Peat❑ So dy Lo m •❑ Clay Loam ❑ Hardpan ❑ AdobeFill Material -, If yes,type ______.___________________ (Plot plan, showing size of lot, location of system in relatiori-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 f ] SEPTIC TANK I ] Size------------------------------------------ ---- Liquid Depth ---------------------.___-- Capacity ---- ---- ---------- Type ---------------------- Material-------- ---- -------- No. Compartments -------------_------ Distance -----•--- -•Distance to nearest: Well ----------_---- ____________________Foundation ----_-------- -------- Prop. Line _-_•___-___-- ........ F LEACHING LINE [ ] No. of Lines _____________ Length of each line---------------------------- Total Length ,__________,.___•--.______._ 'D' Box ------------ Type Filter Material F--------------------Depth Filter Material __.-----------------,------------------._-_- Distance to nearest: Well __---------------------- Foundation ------------------------ Property Line. --------------------- SEEPAGE ___________________SEEPAGE PIT [ J Depth Diat meter ________________ Number ---------------------------- Rock Filled Yes E] No �] Water 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) ------ _ t__ - --- ----- _- - ------------- = --------------- - ---- !� ` ` --------- --------------- (Draw existing-bnd 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-Rulbs'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, 1 shall not employ any person in such manner as to become subject.to Workman's Compensation laws of California." Signed -------------------------------- ---- - -- -------------------- Owner I BY ---- --------------------- ------------ --- c•i Title -- (If other than n i -! PAft3MENT USE ONLY APPLICATION ACCEPTED BY ------ - ---- ----------------------------------------------, DATE ------ ------------- BUILDING PERMIT ISSUED ------------- -- ---- ------------------------------------>--------------DATE ------------------------------------------- ADDITIONAL COMMENTS ---- - ; - ---- -- - i �" --------�--------X �-�---- -------- --- -- -.---------- --- Final Inspection bY= -- - Date _ t ------------- ------------ - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M, X