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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT __ ___ (Complete in Triplicate) Permit No: _�- --_-_--f/ This Permit Expires 1 Year From Date Issued Date Issued __� I-� O •-c0_4D-tr7 � 2 X 7 Application is hereby made to the San Joaquin Local Health District for a permit toconstruct and install the work herein described. This-application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations.. J08 ADDRESS/LOCATI N _ - --__ -- -----------CENSUS TRACT -------------------------- Owner's Name --- - -----------Phone Address .____ --2,j'---_-- Cit Contractor's Name - ---------.License # ------------------------ Phone . --------------------- Installation will serve: Residence;V Apartment House❑ Commercial ❑Trailer Court Motel ❑Other -------------------- Number of living units:-----!----- Number of bedrooms ------ ----- Grinder ------------ Lot Size _ Water Supply: Public System and name ________________-_____------_- ---------------------------------- --- ------Private M Character of soil to a depth of 3 feet: Sand❑ Silt E] Clay F1Peat[-ISandy Loam ❑ Clay LaamA 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.) w NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,! PACKAGE TREATMENT [ ] SEPTIC TANK [ 7 Size----------------------- - ----------- Liquid Depth -------------------------- Capacity -- ------------------ Type -------------------- Material------------ --------- .No. Compartments --------- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---•------------------ LEACHING LINE [ ] No. of Lines ________________________ Length of each line---------------------------- Total Length , 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------_-_________ --------------•-•--- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. ------------------- SEEPAGE -_ _ _ __SEEPAGE PIT [ ] Depth ___________________ Diameter ---------------- Number _ ------------------------- Rock Filled Yes [] No 0 Water Table Depth --------------------------- ----------Rock Size Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit K# -------------------------------------------- Date -----------------------------_- •-) Septic Tank (Specify Requirements) --------------------- ` Disposal Field (Specify Requirements) - ,� ------------ raw 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 ------ -------- ----------------- ---- Owner -- ------------------ -- -- ----- ---- - BY - Title _. 4!I•cA ---- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYBUI ------------------------------------ LDING PERMIT ISSUED --------------------- - -------- ---------------------------------------------------------- ---------DATE -----------•- ADDITIONAL COMMENTS -------------- -------------- -------- -------------------------------------- ------- ---------------------------------------------------------------------------------------- --------- ina Inspection by: . - - -------------------------------------------------------------------------------------- -----------------------------------------------------Date -�- --��- -.� --- Of•------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M