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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------- - --- ------------------- - ------- Permit No.. / �� 4 (Complete in Triplicate) ` I ----------------- S 7 .� ----------------------------------------- Date Issued __--_..�_------- ------ _._. -- --- -- ----------_--------____---------------------- This Permit Expires t 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 L described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: --------- ------- ------ --------JOB ADDRESS/LOCATION ` CENSUS TRACT OOwner's Name �/(/ ----------- Phone I -----W Address � � � ------. City @ -------- ------------------------------L -------License #( ' Phone " Contractor's Name . --------- " I Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court l❑ i Motel ❑Other -------- ---------------------------------- F kNumber of living units:- ----- Number of bedrooms ._��_------Garbage Grinder ------------ Lot Size ---------------------------------_-___.-__. l Water Supply. Public System and name --------------------------------- ------------------ ---------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ ilt❑ Clay-❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ d Hardpan Adobe F-1Fill Material ---------_.- If yes, type ________________-.- i ' (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 p tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ } SEPTIC TANK'[ ) Size------------------------------------------------ Liquid Depth I ------------..------------ Capacity -------_._-_-_- i Ca acitY ---- --------- Type -- -------------- Material----------- -_ No. Compartments _________________ Distance.to nearest: Well ------------------- ----------------Foundation ----------------------.Prop. Line _ - -- -=------- CP -� - c LEACHING LINE [ ] No. of Lines --- ------_------------ Length of each line------------------------ -- Total Length ---------------------------0 !� 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------- Distance to nearest: Well--_-------------------_---- Foundation ------------------------ Property Line. ------------------ ----- - SEEPAGE PIT [ ] Depth ____________________ Diameter -------- Number -------- ------------------- Rock Filled Yes ❑ No 0 Water Table Depth ------------------------- Rock Size - �i Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line .................... ) i REPAIR/ADDITION(Prey. Sanitation Permit# ---------------------------- ------ --.------ Date -----------------------•--------.-1io I Septic Tank (Specify '. Requirements) - - ---- ------------------ ---------------------------- -- ------- --------------------- ! - _ � - ,Requirements) � - --� ------ --�Disposal Field ISpecifY i 1 x- .r.. ----------------------------------------------------------- ------------- ------------------ 3 1 --------- ----=- {Draw existing and required addition on reverse side) f 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 Sass Joaquin Local Health District. Home owner or liven- h 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 i f as to become subject to Workman's Compensation laws of California." Signed --------- ------------ -------- Owner ------------------ ----------------- f (If other than owner) ' FOR DEPARTMENT USE ONLY APPL#CATION ACCEPTED BY --- -------- DATE _ � ` BUILWNGPERMIT ISSUED ---------- ------------------------------------------------------- ---------------------- ---------DATE -----------_------------------------------- ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------- --------------------------- ----------------------------------------- --- ----- ---- ------------------------------------------------------- f ----- - - - - -- -------------------------------------- -------------- Final Inspection by: l Date ._ --------------------------f f SAN JOAQUIN LOCAL HEALTH DISTRICT w i 1 E. H. 9 1='68 Rev. 5M,