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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - - - - ---------- - --------------------- # Permit No: (Complete in Triplicate) ----------------------------------------- ------------- t Date Issued ----- ._�.��3. .i This Permit Expires 1 Year From Date Issued I 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/LOCATION V� -- - - - ----- ----- --- --- -- ----- CENSUS TRACT _-• Owner's Name ------- �'`� -- Phone .��7_�- ----- � -- ---- --- - -kcity -- Address _.._ __. -------- t-� -----License # --ldQ--y' Phone ------------------•----------- Contractor's Name ----- - -- -------- ----- Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other ---------------------------------------•---- Number of living units:--- ----- Number of bedrooms -�-----Garbage Grinder ------------ Lot Size .--G4_ ------ __________________ Water Supply: Public System and name --------------------------•------.------------------------------------•---------------------------- ---------Private Chardcter-of soil to a depth of 3 feet: ` Sand'❑ Silt❑' Clay .❑ Peat ❑" Sandy Loan.1 � lay Loam E Hardpan ❑ Adobe ❑ Fill Material ----- ------ If yes, type ---------------------------- i (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'[ "- -e -- 7 _�___ _____ Liquid Depth 4 ----�_____.____- Capacity4 �io i No. !Compartments yMaterial-- / J Distance to nearest: Well --------__ Q---------------------Foundation ----/10------------ Prop. Line _.,� _.__ .... I � LEACHING LINE No. of Lines ----- Length of each line____ __ _ ________-_-_ Total Length __ u_ 1 .� 'D' Box __/----- Type Filter Material ------;'_?!__Depth Filter Material ______ -------------�i___-.--__-_ 00 Distance to nearest: Well -----o-3;- --- ------ Foundation _.-Ir-------------- Property Line - ____________.____. SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number -- ------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth --------------- ------------Rock Size --------------------- --------------------- ----------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ..-----------------.-- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- Septic Tank (Specify Requirements) ----------"=------------------------------------ ------------------------------------------------- --------------------------- DisposalField (Sp edify Requirements) -----= 1-----------------•---------------------------------------------------------------------------------------------------------- -jk -- -----------------------I------------------------------- ------ i--------------------------------- - ------------------ - �- --------------------, - _ w---------------------- ---- - ._ __ W.: f --�- --------------------------------------------------------------------- ------------- k �i (Draw existing and required addition on reverse side) y� 1 hereby certify./that I have p-repaired this application and that the work will be done in accordance with San Joaquin County Ordinu(nces, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen sed agents signature certifies the,following: 1 "I 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." Signed --------==---------------------- -----� *"� -=�`� - �-�- --------------- caner 44 b ---_ (If other than owner} ` FQR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - DATE _v-�---- --- ------------------------- BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------- --------------DATE ---------------------------------------- ADDITIONALCOMMENTS ----------- ------------------------------------------------------------ -------- ------------------------------------------------- -------------------- ------ ------------------ -------------------------------------------------------------------------------------------------------- ----------------------------- --------------•----------•-•------------------- /f - ------------------ --- Date '`r a -- -------------------- Final Inspection by: - ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT r E. H. 9 1-'68 Rev. 5M