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FOR OFFICE USE: APPLICATION FOR'SANITATION'PERM T �" --------------------------------------------------------- Permit No. (Complete in Triplicate) 1 ED = -------------------------------------- ----------------- __________________________________________ _ A This Permit Expires 1 Year From D„a FIs �e„ 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: JOB ADDRESS/LOCATIO __ CENSUS + J TRACT ------------�- _ _ - PhoneOwner's Name ---------------- ----------- Address --- --- - ------ ...... City ----------------------------------------- Contractor's ---------------------------------•------Contractor s.Name _License # - -,-� !___ Phone -- Installation will serve: Residence ❑ApartmentHouse❑ Commercial ❑Trailer Court ,❑ L Motel 0 Other Number of living units_____________ Number of bedrooms ____________Garbage Grinder -------------Lot Size __f_-J � Z`--_ ��_ ....... Water Supply. Public System and name---------------------- ---------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand Silt❑ Clay E],_ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ------ If yes,type -_._---____________________ ]Piot plan, showing size of lot, location of system 'in relation to wells, buildings, etc. must be placed on reverse side.) - t NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 1` PACKAGE TREATMENT { ] SEPTIC TANKS t Size_ _1--, _ __ ----------- Liquid Depth ------------- Capaci L- ype 001'ki------- Material------------- --- -- No. Compartments --- ----, Distance A nearest: Well --_-_-Foundation ----------- Prop. LEACHING LINE [ j No. of Lines ✓_________________ Length of each line ___ -___ S=�',_ Total Length :__- _ ...._-.___-: 'D' Box ___1_.____ Type Filter Materiat'�5// -(c_�_}Depth Filter Material _,____---� ------------ ............r ' 7 . `w.w�r..W�- Distance to nearest: Well _� -f __tFoundation _ ___x------------ Property Line SEEPAGE PIT [ ] Depth -Diameter T°____________ Number ____________________________ Rock Filled Yes ❑ No .0 4 Water Table Depth- - -------=-----------w"�.r"'-"�--=----Rock Size --------------------- pDistance to nearest: Well ------------- -------------------- n -------------------- Pro Line ---------•----•------- REPAIRfADDITION(Prev. Sanitation Permit#:.___"----___:._=_.j------___ ________ _ Date n�atio Septic Tank (Specify Requirements) -------- - ' ------------------------------------------.------------------------------------------------------- ------ Disposal Field (Specify Requirements) ------- -------------------•-------------------------------------------------------------------_-------------------------------------- � r ----------------------------------------------------------- ------------------ --- -.--------------------------------------------------------------------------------------------- (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 �, , ---------- // BY - c��—------ Title -----.-- - - - (If other than owner)In s FOR DE ENT USE ONLY APPLICATION ACCEPTED B ___.................. ----------------------------------------- DATE _--- ------ BUILDING PERMIT ISSUED - --- ----- ------ -------------------------------------------- ------------DATE - ----- ----------------------------------- ADDITIONALCOMMENTS ------------ ----------------------------------- --------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------- ------------------------------------------- - ----------------------------------------------------- -- -------------------------------- ----------- � - - ------ Final Inspection by: - ------------------------------------•--------------------------------------- Date ------------=------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M -