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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �c- Permit No. --- ----------------- - ------------------------ (Complete in Triplicate) _ � ---------------- Date Issued ---------------- -------------------- --------- ---- This Permit Expires 1 Year From.Date Issue Application is hereby made to the San Joaquin Local Health District for a permit to construct and 'install the work herein --- ---------------- pp with County Ordinance No. 549 and existing Rules and Regulations: described. This application is made in compliance t ' -------CENSUS TRACT -------------- ----------- JOB ADDRESS/LOCATIO . _ Pho Owner's Name r`'�� A -- ---�-�- ---- ------- - ---- -- - ----------- Cit ----- ---------------- ---------------•---- Address - r 1 4 Contractor's Name ----- _--- - - _ ----'-- -----.License# _�d,�•3�7�- Phone ------------------------------ f Installation will serve: „ Residence Apartment Housef] Commercial :[]Trailer Court' ',E] Motel ❑ Other ------------------ ---- Number of living units:___ --- Number of bedrooms ___ ______-Garbage Grinder ____.____.__ Lot Size ______-_____--_---_- Water Supply: Public Systeml and name ------------------------------------ -- --------------------- ----------------•------- ----- -------------Private Character of soil to a depth of 3 feet: Sand'[:] Silt❑ Gay ❑ Peat❑ Sandy Loam Clay Loom .� Hardpan ❑ Adobe'❑ Fill Material ------------ If yes,type ---------------------------- (Plot ---------------- ------- \ t , (Plot plan, showing size�of_.lot,._locafiion-of system in relation to wells, buildings, etc. must be placed on reverse side.) ' r 1 seepage pit permitted if public sewer is available within 200 feet,) W NEW INSTALLATION:. (No septic tank or i PACKAGE TREATMENT [�.], SEPTIC TANK'[ 1 Size--------- -------------------------------------- Liquid Depth --------------------------- Ca' act Type Materia{---------------------- No. Compartments ------- -------- ,1� fiY t Distance to nearest: Well ----------- Foundation ----------------- Prop. Line ---------- ------------------------------- line of eac line---------------------------- Total Length --_----------------•-------- LEACHING LINE [ ] .No. of Lines� _y ---------- _De th Filter Material --------------------------------------- D ---------------- D�Bo�x:____ --- Type Filter Material ----------------- - p Foundation ------------------- Property Line. -------------------= iDistance to nearest: We ---------------- ; ' SEEPAGE PIT [ ] Depth --- -- ----- - ----- Diameter ----=----------- Number` ------ -------------- ____ Rock Filled Yes ❑ No i0 : ' 3 Water Table Depth -------------- =J - '- Rock Size -------------------------------- --------- ---- --Foun dation ------------------ Prop. Line Distance to nearest: Well __________________________ REPAIR/ADDITION(Prev.'Sanitation Permit# —------------ ----- ------- Date - ------------------------ -----1 ! Septic Tank (Specify Requirements) ------------------------------------------- i --- Dis sal Field {Specify Requirementsl ------- --------------------------------------------------------- -------------------------------------------- ---- -- et-t;- ----- - ------ --- -- --- ---- - -------------------------- --- -------- -------- -- (Draw existing and required addition an 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: ', "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." ' f ='�- --- = - Owner Signed ---- . .._�-_ O er ----------------- --- ----------------- �- i '. 4 Title . -- ------------------------_ -------- ------ (If other.than owner) . .w r a } s FOR:DEPARTMENT USE ONLY _.-� DATE APPLICATION ACCEPTED''BY __- ------------------ -------- ------------------------- BUILDING PERMIT ISSUED ------------------------ ---------_---------- ------------------------------------------------------ DATE ------------------------------------------- BUILDING --- --- ---•---- -------- -------- ---- ADDITIONAL COMMENTS ------------------- -------------------------------------- - = ----------- -------------------------- ----------------------- ---------------------- --------------------- ------------------------- -------- -------- ---- - ----- -------- - ---------------------------------------------------------------------- -------- - - - -- ----- - ------- ----- - -- --------- - ..__.Date - --------- -- ----- -��- --- Final Inspection by: __ - - --------------- - - - - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M r