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FOR OFFICE USE: E--------------------------------------- 'PLICATION FOR SANITATION PER, Permit No. (Complete in Triplicate) ------ This Permit Expires i Year From Date Issued bate Issued . .................. Application is hereby made to the San J aquin.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 E s r ' Reg'.u...la..t.i.o..n..s.: JOB ADDRESS/LOCATION -- --CENSUS TRACT ----- Owner's . ..... Name ----•-----------------•-------------------------------- ---------------------Phone ••----------------------------•----- Address --or - 1 CityCr -*�- Contractor's Name --'-- - _ ---------------------License # _4f 9.3-_,X_— Phone ------------------------------ Installation will serve: -Residence ❑ Apartment Nouse,❑ Commercial: Trailer Court 0 € Motel ❑Other ------ el- _ _ -- - �- Garba e Grinder _______._.__ Lot Size ___«^�=�—__— Number of living units:___/--____ Number of`bedrooms___ ____.__ g - --_-..�'�------- Water Supply: Public System and name -------------------------------------------------------------- ------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay .❑ Peat❑ Sandy Loam C] Clay Loam ❑ Hardpan Adobe❑ Fill Material ____________ If yes,type ____________________________ Inl (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) e O NEW INSTALLATION: (No septic tank or seepage pit permitted i public sewer is available within 200 feet,) PACKAGE TREATMENT [ 3 SEPTIC TANK Size____ _ ___ __ __S-------____ Liquid Depth ____V------------------ Capacity� t` _ __,%_ Type •^- ____ Material__ ___ No. Compartments __'_._____-•-_-.___ Distance to nearest: Well ____S-�ad---------------------Foundation _________ Prop. Line -------____ _ _ l LEACHING LINE [ No. of Lines -------- j___ ___________-- Length of each line---------1 �_________--_______ Total Lengthl____......_... 'D' Box _r------- Type Filter Material _ __!�.-------Depth Filter Material ___,l_ __________________________________ Distance to nearest: Well ____6A-------------- Foundation --------!'�----------- Property Line. _--:�~_.._______-_---- SEEPAGE PIT [� Depth ____ _ ...... Diameter ___- �.. Number -----------___________ Rock Filled Yes No C Water Table Depth ------------yv-•------ - -----------------Rock Size X 3 ©_r____ __Foundation ___}f _f._...._. Pro Distance to nearest: Well _______..f'.._---•- - -------_-,-- p. Line --- --------- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date -----------------------------__---) SepticTank (Specify Requirements) ------------------------------------------------------------------------•---------- ................................--................. DisposalField (Specify Requirements) ------------------------ --•----=-_-------------------•-------•----•--•------------------------------------------------•---•--------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------- -------- ---- -- -- - - - -- - - - - -- - -- -•------------- -- - . --------- --- 1 {Draw existing and req uirr --ed ---addition on reversseesidee} 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: "1 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 -------------------------------------------------- -i ------ --------------------------------.Owner f7_ - ------------- --------------------- BY ------------------------------ ---------- ---------------- Title ------- --- -------- i. (If other than owner) FOR DEPARTMENT USE ONLY . APPLICATION ACCEPTED BY ---r... --------------- ------------------------------------------ DATE __ = Y,7 ----------------- BUILDING PERMIT ISSUED --------- --•----••------------------------- --------------DATE -------------•--••--------•---------------- ADDITIONAL COMMENTS - �,�1 "�~ .. `a`'` a ------------------------------------------------- ----------------• -=- -••--•-•----------------- ---------- -------------------------------------------- ---------- Final Inspection by- � - _ ------ ---Date ---�--•��--------------------- -------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M