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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. -�-��--��-- ------- ------- ----------------- ----- -------------- t.. (Complete in Triplicate) '/ -------- ,' Date Issued ---�`-' 6- This Permit Expires 1 Year From Date Issued t 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: JOB ADDRESS/LO �TION -_---CENSUS :TRACT ---------------------• i M " phone: • �'" Owner's Name -- --�.---- --------- - - , ' - �-)------ ----------- -------- ---------------------------- Cityr,-Ve --` -------- Address - + License # one -------------- -----------•--- Contractor's Name ---------- ------------ -- - -------------- -------------------------- I Installation will serve: Residence Apartment House❑fommercial :❑Trailer Court Motel-M.Other:_-e-------------- -----------------�-------- Number of living units:_____] Number of bedrooms "___ Garbage.Gnnder _. ',6 Lot Size ---------------_ �Y '_Private --------- ---------------- Water Supply: Public System and name _______________________________ ------ -- t 1 Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑_Peat El Sandy Loam Clay Loam El Hard an Adobe ❑ Fill Material ------------ If yes,type ---------------------------- (Plot plan, showing size of lotl location of system in relation to wells, buikdirigs, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic--tank-o-r"seepage pit permitted-if public sewer is available within 200 feet,) TANK', PACKAGE TREATMENT [ ] SEPTIC [ SizeVIA-A-eff --- ---=------.-"--- Liquid Depth - ------------------,- Capacity `�.d_�------- Type E' - Material_�-t' ��Q-`No. Compartments - ------- -------- lal -------- Distance to nearest: Well __-____Sb-r__--__________----Foundation _"--1 t'�__r.__<---- Prop. Line -____�_____________ � . LEACHING LINE [Or//No. of Lines -------- -_ Length of each line----------�4-............ Total Length -- 'r " ------------ -.__� i -`-r---- --- --r----- ------ D' Box _ _�J- Type Filter Ma_tera --� � Depth Filter- Mater�af Distance t nearest: Well ... d_--___---____- Foundation ---- ----------- Property Line. S-------------- " SEEPAGE PIT Depth -------- Diameter ---------------- Number ----------------- Rock Filled Yes F] No .1[] WaterTable Depth --------------------------------------- --------Rock Size -------------------------------- Distance to nearest: Well ---------------------------------- Foundation --------------- ---- Prop. Line REPAIRfADDITION{Prev. Sanitation Permit# ---------------- -------------------------------------------- Date ----------------------------------1 Septic Tank (Specify Requirements) -------------------------------------------------------- ----------------------------------------- Disposal Field (Specify Requirements) -------------------------------•----------- ----------------------------- ------ ------------------------------------ -------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------- ------------------------- -------------- (Draw existing and required addition on reverse side) 1 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 t orkman,s Compensation laws of California." l „ . Own er Signed ---�---- ----- Title --, - - ---- ---- -------- -----rB r kc (If other A�awner) FPR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ r ---------------------------. DATE - BUILDING PERMIT ISSUED ------ ---------"--- = ---------------' ";� `' = r = ;':i _ --------DATE ------- ----------------------------------- j ` ------------------------------------------ --------------------------- ADDITIONAL COMMENTS ----------------- ----- ------------ ------- ------------------------------------------------------------------------------------------------ _ f ------- ------- ---- -------- Final Inspection by: _ Date - :: SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M