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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. -------- ------------------- ------------------- (Compl6te in Triplicate) ------------------------- ----- --�-- - --------- ------ 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/LOCATIO --"l ��-- `"` ` ---Phone -------- ---------••---------•---- Owner's Name -- ---- -------------- """-- - - ------ ----- ----------- e- ........ -- -----" - --- --- --- -- -------- - err ----- _Y I Address --------- �- - Cit _ z"` License # f_ -ar_�-- Phone -- Contractor's Name _ .� ------- "Installation will serve: Residence R!rApartment House❑ Commercial ❑Trailer Court "El Motel ❑Other _ ------- Number of living units:_- "-_ Number of bedrooms -"_----Garbage Grinder _"_ Lot Size -". ---- --- Private Water Supply: Public System and name --------------------------------- --- ------------------------------•---------- Character of soil to a depth of 3 feet: WSand'❑ Silt.❑ Clay Peat ❑ Sandy Loam ❑ Clay Loom-0 Hardpan [KAdobe ❑ 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 side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if$ublic sewer is available within 200 feet,} �y SEPTIC TANK' Size_ tiv ~-.Liquid Depth --6'----------------.----- PACKAGE TREATMENT [ ] / yr, � t is' tri t1-4 Capacity!� lGe ---- Material------------- -------- No. Compartments ---------•-----._:..._ Distance to nearest: Well ---------- ------foundation ---------------------- Prop. Line -------•--------•-• ------ Total Length ------------------------ ----- •- d LEACHING LINE j' ] _ Length of each line---------"___--- --'••-"-- a No. of Lines ------------------ -- 'D' Box ------------ Type Filter Material ________________"---Depth Filter Material -----------------.------------.--------- ------- Foundation -------------- a Property. Line ------------------- --- Distance to nearest: Well ____"___"_____ __ --------- 1 Depth --- Diameter ---------------- Number -- ------------------------- Rock Filled Yes ❑ No 1❑ SEEPAGE PIT [ } p ---- -------- I ' WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Foundation -------------------- Prop. Line _-.----------•-------- Distance to nearest: Well _--__-----_-_-__--__----__ - _14 rDte _'.�'----------------------------- REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Septic Tank (Specify Requirements) -------------- ----------- ----------------------------------------------------------- - - n- ---- ---: _ - ,Q�,,� Disposal Field (Specify Requirements) > --�-_f---�-�-- p=: � "`b-,- �- - �• f�.�-e--- -:- -------- --- �IBX � ------ ------t_'1_4- - - ' s .r(Draw existing and required ad ition on reve side} I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin r 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 -- -------------------------------------- ----------------------------- (If other than owner) FOR .DEPARTMENT USE ONLY --------------------------------------- --------- DATE - -------------------- ------------------- APPLlCATION ACCEPTED BY -- ---- -------- ---------�------- --------- -------DATE ------ ---------- ----- BUILDING PERMIT ISSUED -------------------- - - - -------------------" - ADDITIONAL COMMENTS ------------------ ------------------------------------------------------------------------------------ ----------------------------- - ------------------------------------------------------------------ --------------------- -- --------- ------------------------------------- --- ----- - - ------------------------------------------ - Date . ~ -------- Final Inspection by: -- ----------------- - ---------------------- -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.