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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �s� '....................... ... ............ Permit No ....... . ........... (Complete in Triplicate) "--•" .............. 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 No: 544 and existing Rules and Regulations: JOB ADDRESS/LOCATION ..... _.- /. f-- �. ......_.,.:...............CENSUS TRACT .-------------_----_ - Owner's Name .... .. r h - _.Phone .................................--- { Address -------- ... /......... City ... Contractor's Name .. . .. . ..... .... .. .r..�.. .... � �-.License ��/1'�� phone I Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ❑ ❑ Other .....---------- ............................ � l Number of livingunits:...... . Number of b roo Motel _.___Garbage Grinder'-'�-Lot Size .//��._f .�- ...... Water Supply: Public System and name _.... [,�/ .-..•__ __________________________Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loom [] Clay Loam ❑ Hardpan p AdobeFill Material ............ If yes,type ---------............-.__•_- (Plot pian, 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 I ] �/.S�I ------ .......................... Liquid Depth :............:...........: Capacity .. . .... ..... . Type ...... Material:..-__............ No. Compartments ......................_V Distance to nearest: Well . ..................................Foundation ........... Prop. Line ......... l LEACHING LINE Y No. of Lines rf.. __... Length of a ch li e... _.._....... Total Length _...._......,: 'D' Bo Type Filter Material __De th filter Material. p ��. . ............ Distance to nearest: Well Foundation ._.1 ..9...... Property Line j' .. j SEEPAGE PIT Depth .........- Dieter ,, _.`.�.. Number ..__. .....-- Rock Filled Yes� No ❑� Water Table Depth . `�.---------------------------------Rock Size ..�-.... .....__......_. �. Foundation - . .._.. Pro Line ..... ..... Distance to nearest: Well �--� _ ,� . : f __ p. �._f REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date -------------------._..,.--------_.) Septic Tank {Specify Requirements) .............. ---- .......................................... Disposal Field (Specify Requirements) r .._v_.. •----- � i ----•--•..... ........... . ............•. ------ •----- -- --.... ............................ _ .. .....................I........- - _.. ------------------- -----------------------------------.----.._------------------- •----------------..._.._ (Draw existing and 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 Rules and Regulations of the San Joaquin Local Health District. Home owner or licen. sed agents signature certifies the following: 64 1 certify that in the performance of the work for which this permit-is issued, I sisatl not employ any person in such manner ' as to become subject to Workman's Compensation laws of California." Signed .:.. .... Owner BY _.._ .... . .. _ ------------------ - ... ..... ... ........ . ...... ..-----.._.. Title .. t � (If other than owner) FOR DEPARTME USE ONLY f APPLICATION ACCEPTED BY ... . ........ ....... -------- DATE "'.. - --------- BUILDING PERMIT ISSUED ......-- _.... --...... .._...__._...__... -----------........I...... ..........DATE . ..._...---•- --------------...-......... i ADDITIONAL COMMENTS _..._........... ..... ............. L - : ................ -------------------------- -------- Zi_ .... ..-- ......................... Final Inspection b Date ... ... ..�. . P y: ............ - SAN JOAQUI LOCAL HEALTH DISTRICT E, H.13 24 1-'68 Rev. 5M 7172 3 H ,'