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FOR OFFICE USE: I 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 per to construct and install the work herein described. This application is made in compliance with Co my Ordinance No. 549 and existing Rules and Regulations: i f JOB ADDRESS/LOCAT � )_�®'�- -- -_-- ---- - _ ------ 0(------------------CENSUS TRACT -------------------------- Owner's Name ---- ---------------= ---Phone ------------------------------------ 9. ----- -- -- Address Os --= ---- - City = La..�r�.� r-- - � License # �1�3 Phone ------- ---------------------- Contractor's Name ___-__ -------- �- Installation will serve. ,Residence Apartment Nouse'[] Commercial [-]Trailer Court ❑ Motel ❑ Other ------- -------------------------------- Number of living units:_ umber of bedrooms -_-_ _Garbage Grinder ------------ Lot Size _.__ EWater Supply: Public System and name ------------------------------- ------------------------------ --------------------------------•-••------Private Character of soil to a depth of 3 feet: Sand❑ Silt[:] Clay ❑ Peat❑ Sandy Loam Clay Loam EJ E Hardpan (] Adobe.E] Fill Material ------ ----- If yes, type _-_-_________.______-__ 1 (Plot plan, showing size of lot, location of system. in relation to wells, buildings, etc, must be placed on reverse side.) a f r 0 NEW INSTALLATION: (No septic tank or seepage pit permitted-if public sewer is available within 200 feet,[ � I , PACKAGE TREATMENT --[-] SEPTIC TANK f ] . Size------------------•.--------------- ------ Liquid Depth ------------._.-.---,----- r 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 ----------------------! Foundation ------------------------ Property Line. _________________ ...... SEEPAGE PIT [ ] Depth ____ --------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No 0 ' Water Table Depth _________________ ' ------------------------------Rack Size ------------------------------- I 1 Distance to nearest: Well ________________________________________Foundation __________________ Prop. Line ....____--_________.-- � I REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- e Septic Tank (Specify Requirements) _______.__________ _________ is oral Field (Specify Requi emenfis) __ ^" "s "1E ------- -- - •-------- -- ------- -- - --------------� -------- --- ------ --- R sf _•_-.____ __ __ ___________________________ _____________________________________________________-_______------___---__________...______________.______.________________.________________.____- (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 become subject to Workman's Compensation laws of California." Signed ----------- --- ---- ----- --- -= Owner ------ -- BY m - Title ------- (If other than owner) FOR DEPARTMENT -USE ONLY APPLICATION ACCEPTED BY _._ �1 7 --------------------------------------------------------------------------. DATE -----�--------`--------�------------ BUILDING PERMIT ISSUED ------------------------------------------------------------------------------------------- ------------DATE ----------------------------------------- ADDITIONAL ------------------------------------ -ADDITIONAL COMMENTS ------------=--------------------------------------- --------•------------------------------------------------------------------------------------------------ --------------------------------------------------------i ---------------------------------------- --------- -- ------ --------- ------------ ----------------------------------------------------------------------------------------- --------�--- -� - -- ------ a - T --------------- ----------------------------------- -- ----- ---- --- Final Inspection by: - c � Date r� T } SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M