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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. -------- ---------------I 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. 549 and existing Rules and Regulations: i a JOB ADDRESS/LOTION ___ ._ ,--- __.__CENSUS TRACT Owner's NameR.i - -----------Phone - ---------- - ---------- - .Address -------- o city Contractor's Name _ _ --- ---- s c• - c- i-,-r--e-�------ --------------_-License - .-- Phone Installation will serve: Residence.yApartment House�❑ Commerciaf:❑Trailer Court Motel ❑Other -------------------------------------------- Numbe'r of living units:___---- ._ Number of bedrooms __'7--_'___Garbage Grinder ------------ Lot Size Water Supply: Public System and name ---____+,_-_- ,_____•_------_ _- - Private Character of soil to a depth of 3 feet: Sand ❑ Silt E. Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam:❑ Hardpan ❑ Adobe-E] Fill Material -------- If yes, type ---------------------------- (Pl'ot plan, showing size of lot, location of system in relation to wells, buildings, .etc. must be placed on reverse side.) NEW INSTALLATION: fNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK C ] . ,1. Size----- ---------------•-------------- - ---------- Liquid Depth -------------- - --------- Capacity -------------------- Type -------------------- Material- - ----------- ---- No. Compartments ------------ Distance to to nearest: Wel! Foundation ______________________ Prop. Line ----------------------fi �. LEACHING LINE [ ] No. of .Lines .: 1--__ Length of each line--------------------- ------ Total Length ---------------------------- ------I- Type Filter Material ___________________Depth Filter Material ---------_ ---------------------------------- [ ) i Depth --- j --F ------ Diameter Number -- ----' ----------- -- Property Line -------- -- Distance to nearest: Well __-_-___________----__ Foundation SEEPAGE PIT t _________ Rock Filled Yes ❑ No r❑ Water Table - Depth ---- -------------------------------------------Rock Size --_--------- } -- Distance to nearest: Well ----------------------------------------Foundation ------------_----- _ Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# _____-__-_ __. � i ------------ --- Date�----------------------------------) Septic Tank (Specify Requirements) ------------- t ---=------------ --------------------------------- Dis osal Field (Specify Requi l ents) ----------- --------- ---•-- --- ---- Q -d-1±.c____ a 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: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner a as tokecc�&7I_ _*.qct to Wkm n's'lC�ompensation laws of California." Signed --� � . ... i --------------- By -------------1--------- ------ Title ------------ -- ;. _- - -------- -------- (If other than owner) i' ----------- ------------- ------------- - FOR DEPARTMEN USE ONLY APPLICATION ACCEPTED BY------- _________________ BUILDINGPERMIT ISSUED --------------------------------------------------------------------- DATE -------------- ----------------------------- ---------- --- - ------ DATE ------------------- ADDITIONAL COMMENTS _________ __ of -+s-- - ---- -------------------.------------------------ ----------------- ------------- ------------------------- t ----------------- - ------------------------------------------------------ - ------ ----- -----------------------------------------------------------( --------------------------------------------------------------------- --------------- --------------------------- --- ----- - Final Inspection b -G� P y, ----------- - --- ---- --- ------------ -- --------- - - -------- ate � 3 • D - ------------------------------------- - - -- - ------------- -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M