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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) .Permit No. ------------------------------------------- -------------_-_--------_----------____-------------_---_ This Permit Expires 1 Year From Date Issued 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 in compliance with County Ordinance No. 549 and existing Rules and Regulations: y� --- --------------- ._--- - -- � CENSUS TRACT _-�-��----------- JOB ADDRESS/LOCATION -- -- ------ Owner's Name ,e� �- ----------Phone ------------------------------------ Address -------_ ----------- -- City --------------------------- _ --------------- Contractor's Name'-' ame __ _______ �_ _�_ __ t�_.___.License #��r� _-�-- Phone ------------------------------ -------------- Installation will serve: Residence ❑ Apartment House-[] Commercial ❑Trailer'Court ❑ y V Motel ❑ Other Number of living units.-_=--- Number of bedrooms _______Garbage Grinder __________ Lot Size ------ ----- ------ - Water Supply: Public System and name ------------------------------------------------------------------------------------- --------Private [J Character of soil to a depth of 3 feet: Sand'F Silt❑ Clay ❑ Peat❑ Sandy Loam [?Clay Loam .0 �Y 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>> ` , ` r L l L d-- �� / X Liquid .Depth --�--- Capacity -.._d_ ?-Ire : ,__ Type(�J+•Q- Fa- Material e�4']R- -�____ No. Compartments Z______________ V Distance to WeaWell ------------------Sc' Foundation ____�!?__ ____"__- Prop. Line _-:` ----------- LEACHING LINE / No. of Lines ________I______________ Length of each line----- D_-- -------------- Total Length ___ ----------- 'D' Box71� A__ Type Filter Material _____ Depth Filter Material --------- _______________________ Distance to nearest: Well ------------ Foundation -----L_O___.._______ Property Line -----Y"'..._ __._-. _ SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No C] Water Table Depth --------------------------------------Rock Size --------------------------- Distance to nearest: Well ___________________________Foundation -------------------- Prop. Line ............_,........ REPAIR/ADDITION(Prev. Sanitation Permit Y# ________________ _ Date _____________"____________________) SepticTank (Specify Requirements) ----- --------------------------------------------------------------------------------------------------------------------------------------- Disposal Field (Specify Requirements) --------------------------- ---------------------------------------------- ------------------------=---------------------- ---------- -------------------- ----------------- -----I------ :--------------------- ------------------------------------------------ -------------------------------------------- (Draw existing and required addition on reverse side) 1 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 worts for which this permit is issued, I shalt not employ any person in such manner as to become subject Workman's Compen 'on laws of California." Y' Signed ----------------- ---- -------------- Owner BY A --- �----- Title ------- (If�o -----(Ifo er than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .-- -- - __------------------------------------------------------------ DATE _J ~7 a----------`--- ; BUILDING PERMIT ISSUED -------------- -------------DATE ----------------------------------- -- ADDITIONAL COMMENTS COMMENTS --------------------------------------------------- -------------------- ------------------------------------------------------------- ---- ---------------------------------- - -- ------ ----- - ------- ------------------------------------------------------------- ---------- -- --- ----- ---- --- - -- Final Inspection by:. ------------------------ -- - ----------------------------------------Date 3-',2-� rf CS--------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M