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FOR OFFICE USE: I APPLICATION FOR SANITATION PERMIT ' -------------------------------------------------- (Complete in Triplicate) Permit No: ---------=----------------------------------------------- This Permit Expires 1 Year From Date Issued 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: JOB ADDRESS/LOCATI N --------------------------- -------------//--,s---------------------------------------- --------- - ---- CENSUS TRACT --- `5- ------------- i Owner's Name Cd-------- J- -?---------- ----- ------------ - -------Phone ...... ---------- - cAddess ------- -� City --- Contractor's Name ___ _Cf►rResider License # t� 2_ 1__Installation will serve: rce 'Apartment House°❑ Commercial ❑Trailer Court ',❑ Motel ❑ Other -------------------------------------------- Number of living units:------------ Number of bedrooms _______Garbage Grinder ---&------ Lot Size ./__ _________________-_-__--_-_- Water Supply: Public System and name ------------------------------- ---- ----------- -------------------------------------------•-----------------Private D — ! �- o Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay �e—Peat❑ Sandy Loam -❑ Gay Loam ❑ Hardpan ❑ Adobe ❑ Fill Moterial _-_-_-- ---- 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: (No septic tank or seepage pit permitted if public sewer is aJailable within 200 feet,) ! PACKAGE TREATMENT [ ] SEPTIC TANK;( ] Size------------------------------------------------ Liquid Depth _---------___________.__ r Capacity -------------------- Type ------':------------ Material---------------------- No. Compartments ------- --------='' Distance to 'nearest: Well ----------0_________________________Foundation ____________________- Prop. Line ____________- ------- 4. LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ---------------------.------ 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------------- ----------------- Y' Distance to nearest: Well _______________'- Foundation ----------------------- Property Line ____-___-_________-_____ r SEEPAGE PIT [ } Depth -------------------- Diameter -------------- Number __._:__________ ----------- Rock Filled Yes ❑ No I❑ Water Table Depth ________- +' ` -------------- `---' Rock Size --------------------------- Distance to nearest'Well -------1--------------1-------- ------Foundation' ---------------. Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# _..------------------------------------ Date w # ws. ------------------------------ Septic _____-___Se tic Tank (Specify Requirements) ;--- , ------X-----------------------------------`------------------ -- ---------- --- --- ------- ------- ----®- - -- `�-�-F. Disposal Field (Specify Requirements) ___ _e- -------i (1kLs _____A 6t �__3-�_---___ --'- ------------------------------- (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 i 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 -------- -------------------------------------------- Title _. -------- ----- Tother than o ed FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY --- ----- - ---- ---------------------------------------------------------- DATE��-'r✓6 �-------------- --- BUILDINGPERMIT ISSUED -------------------------------------------------------------------------------------------•-------- ----DATE -- ---------------------------------------- ;ADDITIONAL COMMENTS --------------f - - ' a -- ------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------- ----------- -------------------------------------------------------------------------------------------------------------- " ------ -- -------------- ---- - - -- ---- ---------- ina nspection Y '� .1.. ----------------.Date �� �:. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H..9 1-'68 Rev. 5M 1