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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------=-f------------- -- �— {Complete in Triplicate) Permit No. __7 '______ __. ---------------------------------------------------------- Date Issued -------------- ----- 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 compliance with County Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION _________ _____ ._ -_� - "__-_______ CENSUS TRACT _ _. /-_____-____ Owner's Name ------ ---- --------- ------------------------------- ----- Phone ----- - -------•----•----•---- Address ------lS y ?--.6-- ------- ------------------------------------- - � ,,_,p---------------------- - -----.._. city C-i� ----------------------------------- Contractor's Name ---��_X__-_�� _ � ---:-------.License #4&'.�'""`__------ Phone ------------------------------ Installation will serve: Residence partment House-F] Commercial ❑Trailer Court ',❑ Motel ❑ Other -------------------------------------------- f Number of living units------------- Number of bedrooms ___ ,_-nl..Garbage Grinder ------------ Lot Size --->fVXAXF)---------------------- Water Supply; Public System and name ________� r 1_ena1..�—____________________ __-_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 flank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------`----------------------- Liquid Depth ___.---------------------- Capacity -------------------- Type -------------------- Material------------ --------- No. Compartments ----------------.:..._ Distance to nearest: Well ____________________________________Foundation ----------------------- Prop. Line ________________._._.. LEACHING LINE [ ] No. of Lines ________________________ Length of each line---------------------.--- __ Total Length ___________-______________.. 'D' Box ------------ Type Filter Material ____________________Depth Filter Material ------------------------------------ ....... Distance to nearest: Well ________________________ Found ation -__-.____-_ _.__________ Property Line SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ------------- ----------- - Rock Filled Yes ❑ No i❑ Water Table Depth --------------------------__--=--------Rock Size ------------- ------------------ Distance to nearest: Well __________________________.___._____...Foundation --------------------- Prop. Line __..____..____-_-...:_ REPAIR/ADDITION(Prev. Sanitation Permit e# -------------------------------------------- Date ----------------------------------- Septic __________"______________________Septic Tank (Specify Requirements) --- --- ------------ - eJ------ Field (Specify Requirements) ____ __ __ _______�--�__1yrf+--;�-1 --------7�-r1 ----------.------- ---------- -&)., ----------- d'lt '' ------------------------- ------------------------------------- -------------------- (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: "1 certify that in the performance of the work for which this perini{is issued, I shall not employ any person in such manner as to becoa subject to Workman's Compensation laws of California." Signed fr ,� ------------------------------ Owner By ------------- ------------- ------------------------------------------------------ Title - --- ------ --- ------------------------------------------------------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------- DATE --- ."'ZI".�. ------------- ----------------------------------------------- BUILDING PERMIT ISSUED -------------------------------------- ------------------ - - -------DATE ------------------------------------------- - -- -- -- --------------------- ADDITIONALCOMMENTS -------------- ---------------------------------------------------------------------------------------------- ---- ------------- --------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- �. _____________________________________________________ __ Final Inspection by: ---------------------- Date .. j " 'f SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M