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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. �.'l� ---- - ----- --- ------- - _� -------------------- (Complete in Triplicate) ------ --------------------- --------- Date Issued _7��-"=�-4�? This Permit Expires 1 Year From 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: JOB ADDRESS/LOC ION � 7_ ._-_-- ---- - - CENSUS TRACT ---------------------•.._. Owner's Name --------------------------------------Phone AddressS Cit ---- } --------------------------------------------- ---- Contractor's Name -.License # Phone Installation will serve: Residence partment House❑ Commercial:❑Trailer Court i❑ - J Motel [7 Other -------- -------------------- ------ Number of living units:-------/-_ Number of bedrooms-------GarbageiGrinder------------ Lot Size --- -- --- Water Supply: Public System and name ---------------------------------------------- 'f--------------------------------------------------------Private T Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam �Clay Loam_E]Ar � Hardpan F1 Adobe '❑ Fill Materia! _ '--__-.___ If yes,type --------- ------------------ (Plot plan, showing size of lot, location of system in.relation'to wells,_6uildings, .etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seep a pit permitted if public ewer is available within 200 feet,) de p\'� 'I r PACKAGE TREATMENT f ] SEPTIC TANK'[ 11 SizeT _ :_�, ._ __ -:- Liquid Depth __ --------._-_----•--- V Capacity Type -- Material-________________ No. Compartments ----- .-:---- � f Distance to nearest: Well ------ C�- '-----------Foundation ---_-_-/.fl--__--_-- Prop. Line ---• ------------ ---------- LEACHING LINE [ No. of Lines -__--4 _______- ----- Length of each line ________________ Total Length ,__-AL-9............ 'D' Box -- --- Type Filter Material ----------''----------Depth `. lter Material --------------------------------------•----- Distance to nearest: Well ---------4-.c......... Foundation _:-_L-Q"-1-'�""`-___ Property line _-A—.1............ SEEPAGE PIT [ ] Depth ---- - �' Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 WaterTable Depth ------------------------------------------------hock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation .------------------- Prop. Line ........ -------_--- REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------- --------------- Date ----------------------------------} SepticTank (Specify Requirements) --------------------------------------------------------7------------------------ ----------------=- ---------------------------- DisposalField (Specify Requirements) ----------------------------------- ------------------------------------------------------------------------------------------------ ri - --------------------------------------------------------------------------------- -------------------------------------------------------------------------------------- -- - --------- ------------------ ---------- ------------------------------ ----------------------- ------------- (Draw existing and required 'addition on reverse side) ' I hereby certify that I have prepared this application and that the work will be done to accordance with San Joaquin , 1 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 th erformance of the work for which this permit is issued, I shall not employ any person in such manner as to become subj ct, Workman, mpensation-laws__of„Californla." ...-=--- Signed -------------- --------- ----- .-- Owner ------------------- -----------------------•--- BY ---- L Tit{ -----. � JE (If other than owner)' ; ! e i J FOR DEPARTMENT USE ONLY / APPLICATION ACCEPTED-BY----- 7=--=------------ - --- .",-'_` ..""._.DATE��"'"---=�-`---- --------- BUILDINGPERMIT ISSUED -- ----- --------------------------------------------------------- ------------------------------------DATE ---- ---- ------------------------- ------- ADDITIONAL COMMENTS ---------- !---------- -- ------ ----- -------------- - -----------•---- --------•------------------ --------------------------------------------------------------------------------- ------------------------------ ---------- ----------------------3r �� - Final Inspection b Date -----_------------ -----------Y: ----------------- - - - -------- - - - SAN JOAQUIN LOCAL HEALTH DISTRICT 4 E.-H. 9 1-'68 Rev. 5M.