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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 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. 549 and existing Rules and Regulations: JOB ADDRESS/LOC TION .-- - -- OL"i ----------------------- ------._CENSUS TRACT --_-----------__---_-__-_. �f � -----------.Phone -- / a.5l-- ------ Owner's Name - - - -- �;�-°''-`-�- - - -�=�'-`-'--------��-•--_ --- -- - ----:_{� --- �--- - -?J -- ii� Address T 4- 1----- ----- ------'lel _ ------------------------------------------- City -- - -----`'f------------------- Contractor's Name ------ ----- ---------------------------------------------------------------- --------License # --------- -------------- Phone ------------------------------ Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑ Other _ ._-- ri;Y_=-__ Number of living units:________ Number of bedrooms ______)____Garbage Grinder -------__ Lot Size ____________________________________________ Water Supply: Public System and name ---------------------- ----- ---------------------------------------------------------------------------------Private [c Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Cla ❑ Peat[:] Sandy Loam -F] Clay Loam E]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.) `A NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) h PACKAGE TREATMENTr� [ 7 SEPTIC TANK'[ ] Size_--Zjg- ----------- Liquid Depth ---�----•--......---- Capacit/ U --- Type -------------------- Materialhr. No. Compartments _- ___- ----•---- Distance to nearest: Well ______ _____________________Foundation _l�___-________-__ Prop. Line _.3_ .._...__..__ LEACHING LINE [ ] No. of Lines ------�------------- Length of each line_____ _.1 ------------ Total Length _ __•_-.-_--__--.__ 'D' Boxyj�e Filter Material � �_Depth Filter Material Disfian�o to nearest: Well __ a_______________ Foundation -__._____..-------------- Property Line ------------------._ _ 33 - SEEPAGE PIT [ ) Depth ._�_S.'__________ Diameter _______________ Number _-_______I_______________. Rock Filled Yes 1V No i❑ Water Table Depth _________ _ _P____________________________Rock Size _ -- J � Distance to nearest: Well -----/�.`?____----------------------Foundation ____ _______ Prop. Line _ZX-__---.---.-_-- REPAIR/ADDITION(Prev. Sanitation Permit# --------_-------- _!--------------------- Date ----------------------------------) SepticTank (Specify Requirements) ---- ---------------------------------------------------- ---------------------------------------------------------------------------------- Disposal Field {Specify Requirements) -------------- -------------------------------------------------------------------------------- ----------------------------- --- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 as to bec me subject t WorkmMF", ensati.on laws of California." Signed _-_ - _ ---------- ---- - - --------------- Owner BY ------------------------ ---- ----- Title ---- ----------------------------- ------------------------------------ (lf other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYC1"t -------------- DATE _- _l�_ _•6 ------------------- -------------- -- -- ----- - ----------------------------------------- BUILDINGPERMIT ISSUED ----------------------- ------------------------------------------- --- ---------------- DATE - ---------------------------------------- - ADDITIONAL COMMENTS ---- ----------- ----------------------- - --- k --- ------ ' t __ ____________________________________________________________ ______ ______ ------- ------------------------------------------------- ------ ------ Final Inspection by: ------------------------------- � � Date j - --- ------ ------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M