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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------- ------------------------- -- (Complete in Triplicate) Permit No: ------------------------------------------------------_- This Permit Expires 1 Year From Date Issued Date Issued _- - --------- Application -_7Application 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/LOCAT 1 ------ ---- -- --- - -------- - ENSUS TRACT -A-Y-7------------ Owner's A Y-7------------ Owner's Name ..._-- � ------- --- - ------ ------- -- ------------ ------------- --. - Phone Address . ® --------- ----- City -------------------------------- Contractor's Name ._.____ --s --- _ � ------ _. # - Phone _______--________ Installation will serve: Residenc [ Apartment House❑ Commercial :❑Trailer Court 0 Motel ❑Other -------------------------------------------- Number ------------------------------------------Number of living units:_.___. Number of bedrooms ------Garbage Grinder ------------ Lot Size ---------- Water __ __Water Supply: Public System and name -------------------------------------------- I---------- ------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -K Clay Loam jo Hardpan ❑ Adobe,E] Fill 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'[ Size------------------------------------------------- Liquid Depth ---------------•--------- Capacity'------------------ _---------Capacity'-----------------= Type -------------------- Material---------------------- No. Compartments ----------------- I Distance ito nearest., Well ------------------------------------Foundation ---------------------- Prop. Line --------------- ------ S LEACHING LINE [ ] No. of Lines ------------------------ Length• of each line---------------------------- Total Length -----------................ 'D' Box t----------- Type Filter Material --------------------Depth Filter Material ---------------------------------------...-- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. ------------:----------- SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes .❑ No WaterTable Depth ------------------------------------------------Rock Size ---------------------------- Distance to nearest: Well ---------------------------------- Foundation -------------------- Prop. Line --------- r REPAIR/ADDITION(Prev. Sanitation Permit# ---------------- ------------------------- Date ________..,.._..__..__________.__:} 4 r SepticTank (Specify Requirements) ----------------------------------------- --------------------------------r-----------------:-------- - ----------------------------- Disposal Field (Specify Requirements) --�•- mss- --- r ---- $ (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 Sora 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 permit is issued, I shall not employ any person in such manner as to become subject to RWanTs Compensation laws of California." Signed .. -- -` - ---- ='C►wner --- -�.. BY _ Jitle -------- --e�`'i-'LdC �1-{----- ------------------------•---- (if other than owner) FOW DEPARTMENT USE ONLY f APPLICATION ACCEPTED BY ----- _- - ----_._-. DATE ---Cs_-=--� -- ------------ BUILDINGPERMIT ISSUED ---------- ------------------------ --------------------------------------------------------------DATE --------------------------------------__ ADDITIONALCOMMENTS ------------------------------------------------------=-----------_-----------------------------=----------------------------------------------• ----------- ------------------------------- ----------- ------------________________---_-_---__-------________________------_-_-_________-_--_---________---------- , `I_ __ ------------------------------------------- -- ------- ------------------- --- ---------------------------- ---------------------------- - -- - --- ----- - - Final Inspection by- ------ r � ------------------Date , -- —---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 I-'68 Rev. 5M. . - I