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[ FOR OFFICE USE: � APPLICATION FOR SANITATION PERMIT 7 3_S p� -------=------------------------- (Complete in Triplicate) Permit No. -------- ---------73 ------- --•-------------------------------------- - Date Issued -/Y~___-. j 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 wit County Ordinance No. 549 and existing Rules and Regulations: 5 ---------CENSUS TRACT -------------------------- JOB ADDRESS/LO TION ---- - -��-----� -- - ------------------- ------------ -- Owner's Name ----- Phone --------------------"•------- ------ ----- - ----- Address u " ------------------- GitY --- --- =--- ---------- ' Contractor's Name __- - ----�+ - ---License # _ -_ _ Phone ------------------------------ Installation will serve: Residence Apartment House-F-1 Commercial :❑Trailer Court ❑ l Motel ❑Other -------------------------------------------- Number of living units:___.__ Number of bedrooms ------___Garbage Grinder ------------ Lot Size -----I tL_ems-- - '•••- 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 ❑ Adobe F1Fill 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 seep a pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] [ Liquid Depth -- ---,--- SEPTIC TANK' Size__ �- _,,e -�---.------ No. Compartments �....... Capacity .[_ Ype Material - pv y Pro Line ---_ Distance to neares : Well ----------, !_ --------Foundation _---"" _0_� p. Length of each lineTotal Length _� LEACHING LINE [ No. of Lines _---. ------- -- g ,. 'D' Box '_____�_____ Type Filter Material ----- _r.�"-.-"Depth filter Material --------1�""----------------------••---- i Foundation Property Line ------ Distance ,fir to nearest: Well 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# --- ---- ----------------------------------- - Date ---------------------------------- i Septic Tank (Specify Requirements) --------------- -----------------,------------ ----- Disposal Field (Specify Requirements) ---------- --------------------------------------------------------------------- x k , ____________ �_______________________________________________________________. ________.__________________________..____________________.________z____________ ______- __________________________________ (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 --------- ac - = = Owner.. Title - ---------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- _14 ----=-------------------------------------------- DATE _ --------------------------------------- BUILDING PERMIT ISSUED -------k----------------------- ------DATE ------------------------------------------- ADDITIONAL COMMENTS ------------------------ ---------- ----------------------------------------- -------------------- ------------------------------------------------------------------------------------------------------------------------------ - -------------------------------------------------------------------- «- -------------- Final Inspection by: ------ �' ------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M .�