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4 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: -- --- ------------------------------------ -- ----- (Complete in Triplicate) ------- ------- ----- -- ----- --- Date Issued This Permit Expires 1 Year From Date issued Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance -th County LOrdinance No. 549 and existing Rules and Regulations. r - CENSUS TRACT --•----------------------- JOB ADDRESS/LOC N ._ - ---�---- Owner's Name -- -- � -------Phone Address - -'--'.CLQ-------- - --------- - - ----- -- City �} / _ � --- Phone Contractor's Name .____ ------ Installation will serve: Residence [ partment House,(] Commercial ❑Trailer Court l❑ Motel []Other ------------------------------------------- / Number of living units:------- Number of bedrooms _______Garbage Grinder __. ___ Lot Size Water Supply: Public System and name ---------___---- _-------------------------------------------Private 5r Character of soil to a depth of 3 feet: - Sand-'El -Silt❑ Clay Peat❑ Sandy Loam ❑ Clay Loam 'E] Hardpan ❑ Adobe-[-] Fil 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 tank or seepage pit permitted if public sewer is available within 200 feet,) V'; PACKAGE TREATMENT [ I SEPTIC TANK [ ] Size--- --------------- -------------- -a- ---- _ Liquid Depth --------------------------- Capacity---- -------- --------------------.-----Ca acit ------- Type � T e ----=--------------- 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 ------------------------ Foundation ------------------------- Property Line ____--________-----_ 9 SEEPAGE PIT [ ] Depth --------- ___ Diameter Number _______________________ Rock Filled Yes [] No IWater Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well -----------------------------------------Foundation --------------------.Prop. Line --------.--------'--••- REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------- ---- Date ----------------------- _------ --------------------------------------) r Septic Tank (Specify Requirements) "___________ _____ Disposal Fi d (Specify Requirement , `== -- --- _ - r " ------------ - ,01V - � 4 (Draw ex ting and required U ddition on reverse side) A 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 followi.ng:; t "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 become subject to Workman's Compensation I s of California." Signed --- -----------.------------------ Owner - - : i z Title .� ---------- _ - ---- -- ----------------------------------- By ------------------ -----------------------(:� . (if other than owner) 'i FOE DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _- ___ __f_ fi_� 73 .� . -------- - - ------------------- ---------- DATE -----�-- -Z--------------- ------------ BUILDING PERMIT ISSUED -------------------------- ---------------- --------------------------------------------DATE --. --------------------------------------- ' ADDITIONAL COMMENTS --------------------------- - ----------------------------=-------------------------- - ----------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------- ------------------------------------- ------------ ------------------ ---------------------------------------------------------------------------------------------------- --- --- ----------------- FinalInspection b ------------- --------------------- .Date ------ ----- --------I--------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1 E. H. 9 1-'68 Rev. 5M.