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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------- - ----=--------•- .�-�--•�- (Complete in Triplicate) Permit No: ---------------------------------------------- / --------------------------'_ _- This Permit Expires ] Year From Date Issued Date Issued Application is hereby made to the San Joaquin local Health District for a permit to construct and instaIf the work herein described. This application is made in compliartre with unty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .--- �-------- ---- -- - /�,',` CENSUS TRACTI Owner's Name ------- L.Z---------------- --- ---- -- ---- -- - -- -- -- ---------Phone --------------------------•--------- r Address ------•------ /�" -->--- - --- ---- -- - Cit -- ------------------ F Contractor's Name y - `License# Phone -------------------------- -- Installation will serve: Residence Q partment House'❑Commercial ❑Trailer,.Court .!,❑. ,-___.. Motel ❑Other ^- f=' '----------- --- ------ '! { ;e ,r ^ ;er Number of living units:___.r.-.__- Number of bedrooms ----------- Garbage Grinder ------------ Lot Size ------------------------------ Water -__---_--.___-_--__ _ ---Water Supply: Public System and name ------------ --------- -------- --------------------- Private. Character of soil to a depth of 3 feet: Sand'E] Silt❑ 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 side.) I NEW INSTALLATION:- ,,(No septic tank or seepage pit permitted ifpublic sewer is available within 200 feet,) 4 PACKAGE TREATMENT{ ] SEPTIC TANK[ ] size----____'-------------- _------•^_------:-- Liquid Depth ------------.------------- \ 1 Capacity ------------- ------ Type -------------------- Material` ------------ No. Compartments Distance' to nearest. Well / F r -------------------------Foundation ` ----- ------ Prop. Line ------------- -------- LEACHING LINT [ ] ` No. of Lines ------------------------ Length of each line---•:L'-------.-__------___- Total Length ----------- r 1 D' Box �__T_______ Type Filter Material' -------------Depth Filter Material ---------------------- Distance• to nearest: Well ------------------------ ,Foundation ----------------------- Property Line ---_-_-_._:---__._.:-__- SEEPAGEPIT [ ] Depth - ---- ------ Diameter ----------------!Number.-,'--#... - ----------------- Rock Filled Yes ❑ No i❑ Water Table Depth _--------------------------------------------- �• Rock•Size -------------------------------- -Distance; ---------------------------- -- T Distanceao nearest: Well ____`�___________________`___. ___-_-_Foundation 1 ------ Prop. Line ----------------_--•- r ' REPAIR/ADDITION(Prey Sanitation Permit s# ---------------------------------- 1- Septic-.Ta'nk (Specify Requirements) ---- ---- 7 ------------- ------------------- __Z Disposal Field (Specify Requirements) _ ---- ... ------ k--- - x _: ------------= ------ = e -'---------------------------------------------------------------- ----------------------------------------------------------------------------------- 1 i (Draw existing and required addition on'reve'rse,side) 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: t k "I certify that inthe,performonce.of the-work_for.which this_permit is-issued,_i shall not employ any person in such manner as to becomes ct to Workman's Com 'on laws of California." Signed -------- ------------- -- ------------ ---------- Owner --------- - BY { - }-------------------- -- ----------- " -'----- Title -- 'V�-- -------------------------- !f other than owner OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - v ----- ---. DATE BUILDING PERMIT ISSUED --- -- - DATE ADDITIONAL COMMENTS .. -------- --------------------------------•------------------------------------- 4 ----------------------------------------- _------ -------------------------------------------- -------------- --------------_----------------- ----- __ _________ _ __________________________________________________________________________________________________________________________ = ` l -------- ---- _ Fina Inspection by: - ._.Date ( SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M,