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VA- . FOR. OFFICE USE: APPLICATION FOR SANITATION PERMIT 3; �0 ------------------------------------------------------ Permit Na. __7T-:-- --- (Complete 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 per to construct and install the work herein described. This application is made incompliancewith County Ordinance No. 549 and existing Rules and Regulations: J013 ADDRESS/LOCATION `---- �--L.---------�"--- '`-9F. CENSUS TRACT Owner's Name ---- 44!, ---------------------------------------------------;-------------------Phone Address -----------e _00_90------ '--------------------- City - ---------------------------------------------------------- Contractor's Name -------------------------- --------------------------------License # --- Phone Installation will serve: Residence.Lp Apartment House❑ Commercial ❑Trailer Court l❑ Motel ❑Other -------------------------------------------- Number of living units:------------ Number of bedrooms ------------Garbage Grinder ------------ Lot Size ----------------_____--_---------------- Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt 0 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'( ] Size------------------------------------------------ Liquid Depth __------------------------ Capacity --------------------- Type -------------------- Material-------- ---- No. Compartments ------------....._- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ._..---------_----- LEACHING LINT: [ ] 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 i❑ Z Water Table Depth ------------------------------------ ----------Rock Size -------------------------------- t Distance to nearest: Well -------------------------------•--------Foundation -------------------- Prop. Line ----.-_.--......... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) J Septic Tank (Specify Requirements) --- ------- --------------------------------•--------------- -------•-- p Disposal Field (Specify Requirements) ---------------- __ --------------------------- ---------- --------------------------------------------- -------------------------------------- -------------------------------- ------------------------------------------I------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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' Compensation' laws of California." Signed '! s � -- -. . - & r------------------------ Owner By ---- -------------------------------------------------------------------------------------------------- Title -- --------------- ------------------------------------------------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ------ - ----------------------------------------------------------- DATE --------------------- BUILDING PERMIT ISSUED -------------------------------------------------- ------------ ---------------- --------DATE ------------------------------------------- ADDITIONAL COMMENTS ------------------ ----------------------------------------------------------------------------------------------------------------=--------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------- ------- ------------------------------------ --------------------------------------------------------------- ----------------------------- ----------------------------- -------- - _ ---------------------------------------- - Final Inspection by: -------Date -- }- -- ------------------ ------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M