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FOR OFFICE USE: e 3 APPLICATION FOR SANITATION PERMIT Permit No:". ------ ---------- - ----- ----•- -- 7.--_-:� }�----- ► t � (Complete in Triplicate) --------- ------------------- ------------- ----------- Date Issued -�- i This Permit Expires 1 Year From 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 j� / - -- ` CENSUS TRACT 1` TION , f �'-�--------JOB ADDRESS/LOCA Owner's Name ------- --------------------------------- --Phone Address __f� �-- ------- ---- City _ ---- Contractor's Name 4 .- --y�'`" -"----- License # � y17 Phone �� /� 1 �Dl. Residence �artment House,] Commercial❑Trailer Court-❑ Installation will serve.. -- Motel ❑ Other _ - _ ` t Number of living units:...../-_w-'Number>of-bedrooms ______Garbage Grinder ------------ Lot Size ------- Water Supply: Public System and name _________----------------------- --- - - _--_Private El of soil to a depth of 3 feet: Sand❑ Silt[I Clay [-] Peat ElSandy.Loam 0 Clay Loam----- oam ❑ ' ' Hardpan ❑ Adobe-D�r 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.) NEW INSTALLATION:I (No septic tank or seepage pit permitted if public sewer is available within 200{feet,) PACKAGE TREATMENT [ I SEPTIC TANK'[ ] Size-------------------------------1 ------- Liquid Depth -------------------------- Capacity -------------------- Type -------------- ----- Material---------------------- No. Compartments ------ ---.--------- -- ` Distance to nearest: Well ------------------------------------ ouni Foundation ---------------------- Prop. Line ---------------------- ., z LEACHING LINE [ ]1 No. of Lines -----.------------------ Length of each line -------------------- ------ Total Length ___-_____--.---..----------- 1 # b' Box -------- -- Type Filter Material --------------------Depth Filter Material ----------- ---------------------- � _. _ Distan.ce to-nearest: Well _.______�_____._______ Foundation '.___."_____='r"""�"" 'Property'Line --"""""----------------- I SEEPAGE PIT Depth --- Diameter ____-.______':__ Number ------_-------- ----------- Rock Filled Yes ❑ No i❑ Water Table Depth -------------- s-------------- --------------------•-----------Rock Size -------- ;---- 4 Distance to nearest: Well ----------------------------------------Foundation ------ ------}----- Prop. Line -----------•---------- I REPAIR/ADDITION(Prev. Sanitation Permit# -"-------------------------------------"---- Date ------------------=_-_••-- -----) Septic Tank {Specify Requirements) ------------- ------ --------------------- ------ ------------------- - Disposal Field (Specify Requirements) "-" - ----------- i - - '` ______________________________________________________,._____ -----------o _...., 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 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: `„v l "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 berg su ject tow man' 'ompen3ati.an s of California." Y k v e� Signed __L_0 Owner f BY -------- ------ ------------ � -- G ---- ----- -------------- - Title -------------"----------- ------- ------- -------------- (If othef-T_0? owner) FOR DEPARTMENT USE ONLY # APPLICATION ACCEPTED BY _____. DATE ------- - -` ��------ ---- ---------------------------------------------------------------------------- BUILDING PERMIT ISSUED -------------------------- -------------------------------------- DATE = ADDITIONAL COMMENTS -------------------------- ----------- - :-- - -- ' ------------------------------------------------- --------------------- ------------- -------------------- - - ------------------------------- .�, - .. ----- - ------------------------------- ----------------------- -- -------------------- ------------ ---- ----_-- --- ---- ------- &. - ------ f --- ------------- n Final Inspection by: f t � --------------Date ��---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT ' E. H.'9 1-'68 Rev. 5M