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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ------------�- (Complete in Triplicate) ��=7- - Date issued �� " 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: .______ ------- ------CENSUS TRACT --•-----------•------ JOB ADDRESS/LOCATION .. Owner's Name . . .... ----------------------- ------------- --�I�_5,�9�$--------------- - -------- ------Phone 5� - City ----- -------- -------- --•- ---- ---------- ------------------------ Address -- -------- � - Contractor's Name -. - ------.License # Phone Installation will serve: Residence MApartment House❑ Commercial {]Trailer Court ',❑ Motel ❑ Other -------------------------------------------- t of living units:----i------- Number of bedrooms ______Garbage Grinder ~'�---- Lot Size ---- --------------- Number -------------------------- - Private Water Supply: Public System and name -------------------------------------- -------- --------- - Character of soil to a depth of 3 feet. Sand'❑ Silt❑ Clay U Peat❑ Sandy Loam ❑ Clay Loam ;❑ t Hardpan ❑ Adobe ❑ Fill Material " -- If yes,type ---------------------------- \ (Plot plan, show ng size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.} NEW INSTALLATI N: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) r d SizeC � � ------------- Liquid Depth __ ---------------- PACKAGE ----- - PACKAGE TREATMENT SEPTIC TANK [ ] • ' a �2UD Type --- Ca ac; �� -�� -Material-- *+�rz�------ No. Compartments __ l-. - ��r e---Foundotion �d-------------- Prop. Line _ -------- .. Distance to nearest. Well .__-____ _______________- LEACHING LINE " j ] No. of Lines -.-3----------------- Length of each line---_.v------------------ Total Length -----••----` - 'D' Box ----✓--- Type Filter Material e -Depth Filter Material ____�q- ---- Q w -- �0 "1O ----------- Foundation ��------------- Property Line --______--- Distance to nearest: Well ----.___.___" SEEPAGE PIT [ ] Depth _"------------------ Diameter ---------------- Number ----------------------"----- Rock Filled Yes ❑ No C Water Table Depth - ---------- -------------------------Rock Size -------------------------------- r Distance to nearest: Well ____.___-____--------------------------Foundation -------------------- Prop. Line --------- --------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------- Date ----------) M - --------- Septic Tank (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: f "I certify that in the performance of the work far which this permit is issued. 1 shall not employ any person'in such manner as to become subject,toW `r an's Compensation laws of California." Owners l � - - ----------------------------------------------------------------------- Signedx- � --- �� -- -------- - Title ------------------- -------- ------------------ -------------------- ------- (If other than owner) FOR DEPARTMENT USE ONLY 4 A ----------------------------------------------------- DATE _..3'-a��1 APPLICATION ACCEPTED BY - - -- -- -- ----- ------- -------- ---DATE ------------------------------------------- BUILDING .. -------•- ------- -------- --------- BUILDINGPERMIT ISSUED.: = ----------------------------------------------------------- ----- -- -- gDDIT10NAL CO MEN75 -- -------------- A .�--._l��P cls ---------------------- - ---- J--- -- --- ------------------------- - -- -------------- -------------------- ----- - -------,Date -------'- - --- - --------- --- ---- �r Final Ins ecfiion b L SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.