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FOR OFFICE USE: _s APPLICATION FOR SANITATION PERMIT --------------------------------------------- -- --- (Complete in Triplicate) Permit ti ---------- ----------------------------- ---------- i Date Issued1 -73 ______ 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 compliance with County Ordinance No. 549 and existing Rules and ull'' ns: JOB ADDRESS/LOC) -- --- ------ ----- ---- - --- - -------�C� ENSUS TRACT -------------- ----------- cc Nam __-- Phone -----------_ ---------- -------------------- ----- - ---------=- Address ---- 1 � � �( City 1 Contractor's Name ---------- -d-- --------- / ---I`L_-_.License # !-� - -- Phone ------------------------------ Installation will serve: Residence partment House❑ Commercial ❑Trailer Court ;❑ }} Motel F1 Other -------------------------------------------- Number of living units:-------.f- 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❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan L,_If Adobe ❑ Fill Material ------------ If yes,type ______________a --:--_- (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' ,/ r [ a [� Size-� �----�`--%-------x•--f----- Liquid Depth ---�-------------- - Capacity�PPIXV Type Material No. Compartments -2-------- Distance _Distance to nearest: Wel! ---------- 10Lf, _______--Foundation __�a___-____________ Prop. Line _-__4....___.._.. r LEACHING LINE [ No. of Lines --------- - l X Length of each line______`-fg_______________ Total Length ------------------ 'D' ___-___-___-_-__ 'D' Op "f Box __:_1.____._ Type Filter Material ______�__�___.Depth Filter Material ____,_�_�__f�___-_________________________ Distance to nearest: Well _______ 0__1_______ Foundation ------C ------------- Property Line _____________________ K SEEPAGE PIT [/fes Depth ____-__._-______ Diameter ___.�_�__. Number ____._�_____�_______ Rock Filled Yes � No ❑ Water Table Depth ---------------cY_'Q_1-f----------------Rock Size _1t_3-----_.--- r f Distance to nearest: Well ___________�'_Q�__________________Foundation ----�_C]_._r______ Prop. Line ______r. _..__---- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _______________________________- Septic Tank (Specify Requirements) ------------------- ---------------------------••-------------------------•- r Disposal Field {Specify Requirements) __________________ __________-_.--.-_.-___.._______._ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------- ------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------- (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 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." Signed ----------------- ------------------ Owner--- --- -��- JIf BY ---- ------------ ------------------------------ - - `'---------- - ----------------------- --- - other than owner) Aop FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ ------------------------------------------- DATE - BUILDING PERMIT ISSUED ------- -- --------------- ------------------ --------------DATE ------------------------------------------- ADDITIONALCOMMENTS -------------------------------------------------------------------------- -------------------------------------------------------- -------••-•---------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------, ----------------------------------- ----------------------------------------------------------------- ---------------------------------------------------------------------------------------------------- --------------------------- ---- ---- - -- -- --------------------- - -------------------------------------------------------------------------------- j Final Inspection by: ------------------------------------------------- --------------- Date -/ ------------- --- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M I