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FOR OFFICE USE: AIPPLICATION FOR SANITATION PERMIT Permit No: --------------------- -, (Complete in Triplicate) Date Issued .-_t_ �. `O 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 co fiance with County Ordinance No. 549 and existing Rules and Regulations: I �i JOB ADDRESS/LOCA N . 11�.-��' ---------_CENSUS TRACT ' Owner's N - - ---- ------ - = Phone --------------------------•-----•--- - -- --------- - --- Address E CifiY r! ---------- ------------ ----C i r -a -4 "License # C- d- Contractor's Name -._--.-- Phone ______________________________ Installation will serve: Residence partment House❑ Commercial :❑Trailer Court [] } Motel ❑ Other --------- - - Number of living units:"-- ---- Number of bedrooms -- -_.Garbage Grinder Private Lot Size ___G� - '"�--=-- _ Water Supply: Public System and name ___________________ _ _______._______-__-- -•--------------- [� Character of soil to a depth of 3 feet: Sand'❑ ❑Silt. Clay E] Peat E] Sandy Loam Clay Loam ;❑ ! Hardpan ❑ Adobe❑ Fill Material ------------ If yes, type ---------------------------- (Plot plan, showing size of lot, system in relation to wells, buildings, etc. must be placed on reverse side.) \ �location of s t I NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT [ I SEPTIC TANKacit ,---- Type ] Size------------------------------------- Liquid Depth -------------.------ CaT e -------------------- Material---------------------- No. Compartments -----------_-------- Capacity --------- - Distance to nearest: Well ------------- ---_--Foundation ---------------------- Prop. Line ----------- LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ----------------------------- D' Box ------ Type Filter Material --------------.-----Depth Filter Material -------------------- ----------------------- Distance to nearest: Well ____---___ ------------- Foundation --------- -------------- Property Line ------------------- SEEPAGE PIT [ ] Depth ---- Diameter _--___---__-__- Number "--------------------------- Rock Filled Yes E] No I❑ I Water Table Depth ----------- --------Rock Size -------------------------------- Distance to nearest?Well ----------------------------------------Foundation ----- --------------- Prop. Line --------- ------------ I REPAIR/ADDITION(Prev. Sanitation Permit�# -------------------------------------------- Date ---_------------------------------) Septic Tank-(Specify Requirements) -------"----------- -------- --------------------------C-------------- - - -------- - ------- --- ------- -----•--------------- Disposal.Field Specify Requirements) ____ .�</�-------- --- --- -- --- 1 (.--------------- -------------------------- —s ----- --------- --------- - ----------------------------------------------------------------- ---.-:_ _;__--- --=--=-------- ------------------------------------------------------- ` ' 1 (Draw existing and required addition on reverse side) I.hereby certify that 1 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 become subject to Workman's Compensation laws of California." i Signed -------- ---------------- ---- '" _ _ Owner - --'-- --•�- .S`"..�_ Title ---- - -- --- -- --------�"� �---'-------- owner) -------- (If other than ow I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE - -----_ -- ------- BUILDING PERMIT ISSUED ------------------ - --=------------- DATE ADDITIONAL COMMENTS ------ ---------------- --------------------------------------------------------------- ----- ------------------------------------- ---- --------- -------------------- ------------------------------------------------------------ -------------------------- ----- t -----------•------ ---------------------------------------------------------- ------ 7 _ Final Inspection b -_-- _-----.Date .- ------ --'--`- ------------ I SAN JOAQUIN LOCAL HEALTH DISTRICT . E. H. 9 1-'68 Rev. 5M