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FOR OFFICE USE: � � APPLICATION FOR SANITATION PERMIT Permit No. --"��- --------------------------------------------------------- - 1 (Complete in Triplicate) _ ----------------------------- --------------------- a- S Date Issued -------------------- This - ------`- 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: JOB ADDRESS/LOCATI - ----CENSUS TRACT Owner's Name - _.,t-.�x-----. - " " ------..-Phone w 19---�� AddressfQ_- _ ". ------------------------------ City ------------------------------------------------------------- Contractor's Name 4-4 S�/ yw�'.3� License # "p �, -- - Phone - ------- -- Installation will serve: Residence �partment House-M Commercial []Trailer Court ',❑ t aMotel ❑Other -------------------------------------------- Number of living units:---- _-__ Number of bedrooms .7---- Garbage Grinder - ---_-- Lot Size If- Water Supply: Public System and name -___-------------------- '-- -----------------------Private Character of soil to a depth of 3 feet: Sand❑ Silt ff Clay .❑ Peat ❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe'❑ 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 sided NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------- Liquid Depth ---------------------.----- No. Compartments -_"------- capacity ----------- --- Material---- --- -------- p ----------- Q Distance to nearest: Well --------------- ---------------------Foundation ------------------ --- Prop. Line ------------------------ LEACHING ------- - ------LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length -----------------•.--------- 'D' Box ..- ------- Type Filter Material --------------------Depth Filter Material ------------------------------------------------------ .-- --------------------------------------- Distance to nearest:_Well----I _---- --------- Foundation=" '`'-"--'-`'"Property Line- ----- ' SEEPAGE PIT [ ] Depth _--.----- Diameter - ------ ------ Number -_- Rock Filled Yes No Water Table Depth ----------- ----------------- ------------------ Q Rock Size -------------------------------- Distance ---- --------------------Distance to nearest: Well -------------------------------------- Foundation -------------------- Prop. Line ...................... t REPAIR/ADDITION(Prev. Sanitation Permit+ -------------------- ---- Date --------------.------------- .�_. Septic Tank (Specify Requirements) ----------------""-.- ---- -e--- - Disposal Field (Specify Requirements) _-" ----- ------------ - ----------------------------------- - d _ �3�3enaonrequiredx " ----------------------------------------- (Dr exi addition on verse si e) 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 bec e, s ject.to ork n's Compensation laws of California." j Signed ---------- Owner [If other than owner) -------- Title ----------------- ------------------------ ------------------------- ( FOR .DEPARTMENT USE ONLY 71 APPLICATION ACCEPTED BY . - DATE "- -� - f BUILDING PERMIT ISSUED --------=---- ---- -- ----DATE ------- --- ----- ----- ---------- --------------- ADDITIONAL COMMENTS -------------------- _-----" _._' -, -------------- -- ------- --------------------------------------------------------- --- I?- -------------------------- Final Inspection b Date .-_�-�-`-�� -------- ---------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT f i. E. H. 9 1-'68 Rev. 5M w