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FOR OFFICE USE: J " APPLICATION FOR SANITATION PERMIT {Complete in Triplicate) Permit No. _____.._---- This Permit Expires I Year From Date Issued Date Issued __��-7 ApplicationJs 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 un_ty Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCAT34 _ '- ------------ --------- --- -------------------- -- - ----------------------------------CENSUS TRACT Owner's Name ---------- -- ---------------- ------------------------------ Phone -- -- ----------------- Address -------- = a� --- r) .__. Cit / --------------------------- ----------------- Contractor's Name ---- -y---_ L -------License # //V --- Phone ------------------------------ Installation will serve. Residence ❑Apartment House�❑ Commercial []Trailer Court Motel ❑Other 4 l 4- Number of living units_____________ Number of bedrooms ------------Garbage'-G-r rider-------- Lot Lot Size _---__._______.-_______.________________- Water Supply: Public System and name -_________________ _ --------------------------------Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam f 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,) T PACKAGE TREATMENT { ] SEPTIC TANK'[ ] ------------------- _Size__________________- ------___ Liquid Depth -------------------------- Capacity -------------------- Type --------------------- Material------------------ No. Compartments Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line __----.------•-.-_.--. LEACHING LINE [ ] No. of Lines ________________________ Lepgth of each line---------------------------- Total Length --------------------------- 'D' Box ------------ Type Filter Material ____________________Depth Filter Material __---_____________ Distance to nearest: Well _______________"_______ Foundation ------------------------ Property Line -_________...__..._.__. SEEPAGE PIT [ ] Depth ___________________ Diameter ---------------- Number --------------- ------------- Rock Filled Yes ❑ No Water Table Depth ------------------------------------------------Rock Size ----------------------------•--- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line _--------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------- Date ---------------- ) Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------------------------------- Disposal Fi d (Specify quirements) "____xl- -[ ,� —l- " -- ------ -------------------- ------------------------------------------------ -------------------------------------- ----------- ---------i ---------------------------------------------------------------------------------------------- (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' Compensation laws of California." Signed ------------------------------------------ - Owner - --------------------- ---- -- -- -------- --- � .�¢ �/` BY ,!1/i Z r `�Q Title ------iC-ei- ---yA rt--�J-� (lf other than owner FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - -- --'----- ------- - --------- -------------------- ------------ DATE ------------ BUILDING PERMIT ISSUED --------------------------------- -----------------DATE ADDITIONAL COMMENTS -------------------------------- --------- ---I------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- ---------------------------- --------------- ----------------------------------------------------------- -------------------- --------------- ------- ---- - --------------------- - ------------------------- ------------------ Final Inspection by: ------------ - ------ -- ----------------- -----.Date ---- --'---------------------------- SAN /`.- -. -- ----------------------------- - ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M