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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------ ---------- -------- --•----- Permit No. ZG-/� (Complete in Triplicate) --------------------- --------------------------- ---------------- This Permit Expires I Year From Date Issued 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: CT JOS ADDRESS/LOCATION -�� ---_--_-. opartment -------- --------------- CENSUS TRACT S 7 b Owner's Name -------------------------------- ------.Phone .----------------------------------- Address ------------ - d f --- - . Z. City --- _ ---- -- " - ---------------------- ----------Contractor's Name ---- = ,License # 1 0 .� PhoneInstallation will serve: Residence �❑ Commercial;[]Trailer Court Motel ❑ Other -------- ----------------------------- Number - ---= -- 'Number of living units:- ------ "- Number of bedrooms -_'<__Garbage Grinder --------- Lot Size ---------------------------------- -------- Water Supply: Public:System and name --------=---- ---------- --=------- -- ----------------------------' =----------------------=---------Private i Character of soil to a depth of 3 feet: Sand[] Silt El Clay E] Peat E] Sandy Loam'-E] Clay Loam :❑ i r Hardpan „L'f/ Adobe'❑ Fill Material ------------ If yes;type ---------_----------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placedF on reverse side.) NEW INSTALLATION: (No septic tank or seepage.pit permitted if public sewer is available within 200 feet,) ' PACKAGE TREATMENT { ] SEPTIC TANK [ ] Siz ---------------------------------------- Liquid Depth -------------------------- Ca acit ------- Type -=-- -Y------------ Material---------------------- No. Compartments ------------- -:---- x Distance to nearest:'Well ------------------------------------Foundation ---------------------- Prop. Line ------------------ LEACHING LINE LINE [ ] No. of Lines ------------------------ Length of each line------- -------------------- Total Length -----------.-------------.-- 'D'B x .-_--.....-Type Filter Material --------------------Depth FilterMaterial ------------------------------------------ j y Distance,to nearest: Well ----- Foundation ------------- -"""--- Property Line ---------------------- SEEPAGE PIT [ ] Depth -------------------- Diameter _-------------- Number --------------------------- Rock Filled Yes ❑ No l❑ I Water Table D Depth -------=----" -{- ----------------- ----------Rock Size -------------------------------- Distance ------------------------ -----Distance to nearest: Well ----------------------------------------Foundation ---------------.---- Prop. Line -.------__---------" - I REPAIR/ADDITION(Prev. Sanitation•Permit# _---:- ---" ------------------'"--- Date ----------------------------------) Septic Tank (Specify Requirements) ----------�a� -------- ----------------------------------------------- ----------------- ---------- ••------------------------- - Disposal Field (Specify Requirements) --- ----- 4 r ,----- ------------- 2 ci , ----------- -- 3 f ' (Draw existing and required addition on reverse 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: "I certify that i e performance of the work for which this permit is issued, I shall not employ any person in such manner as to become u7 t to Workman's Co sation laws of California." Signed ------ --------- Owner By ------ - Title .- -•----------------------------------------------- i (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - -- ------------- -------------- � --------------------------- DATE - D------- --------- BUILDINGPERMIT ISSUED ------------------------------------------------- --------------------------------------------------------DATE -------------•------------ ---------------- ADDITIONALCOMMENTS --------------- ------------ ------------------------------- --------------------------------------------------------=-------- ------------------ ------- ---- - ----------- f ---------------------- -------- ----------------------------------------------------------------------------------------------------------------------------- ---------- ------------------------------------- - s - Final Inspection by: �° Date a " - ---------- -- ----- - --- --- - ---------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT X E. H. 9 1-'68 Rev. 5M