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� e FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT k ----------------------- ----- ------------------ ' (Complete in Triplicate) Permit No: ---------------------=---=------------ ____________________________________________ This Permit Expires 1 Year From Date Issued Date Issued _4�__l __ .� 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 with County Ordinance No. 549 and existing Rules and Regulations: "1 { 1 1 JOB ADDRESS/LOCATION - ---------�-----------=--' ------ .� ------ ---------------CENSUS TRACT------------------------ Owner's Name Phone Address - ------------- r = --- --------------- City ---- .. . .- Contractor's Name -------- I ` �------------- ----'--------- -------License # Phone ---------------------•-------- r Installation will serve: 'Residence�Q Apartment House-[] Commercial ;❑Trailer Court ;❑ Motel 0 Other -----------/--- ----------------------------- Number of living units:------ Number of bedrooms ---!__-__Garbage Grinder --- ------ Lot Size __r�-~�'�r_rE-r ------------------- Water -'Q'^- ____ ---Water Supply: Public System.and name ---------------------------------------------------------------------------------------------------------------Private] Character of soil to a depth of 3 feet: Sand'❑ Silt[] Clay ❑ Peat❑ Sandy Loam [) ' Gay Loam C1 k Hardpan ❑ Adobe � Fill Material .__._.._- If yes, type --------------°r.__________ N (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------------------------------------ ---- ------ Liquid Depth ----_______-___.'____._-. t Vy Capacity--------------- -- Type -------------------- Material_ ------ No. Compartments ( ,- Distance to nearest: Wel! -------------------------Foundation ---------------------- Prop. Line ------------- ------- LEACHING - LEACHING LINE [ ] No. of Lines ________________________ Length of each line------------------ ---_ Total Length ----------------------------- 'D' Box _�__:___--_ Type Filter Material_____________________Depth Filter Material t - Distance'to nearest: Well ________________________ Foundation ------------------- Property Line _____-________-.--:---. SEEPAGE PIT [ ] Depth _A ----------- Diameter ________________ Number ----.----------.------------ Rock Filled Yes No [j Water Table Depth ---------------------------------------=--------Rock Size __.----------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ___________________________________ 1 -------- Date - --- -- ----------------- ISeptic Tank (Specify Requirements) ---- --- -------- -------------------------------------------------------------------------------------------• --------------------------- I 'I , DisposalField (Specify Requirements) -------------------------------- -------------------------------------------°-------------------------------------------------------- SO -------------------- -------------------------=------- ,., --- 3a-�--`-------------------- ---------------------------------------z,-'lG-- -- �" -------------------------------------------------------- --------------------------------------------- ---- 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, aInd 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 rkman's Compensation taws of California." t --- Owner Signed -- By --- ------------------ c - -�,--fir - Title _ �.�.. (If other than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- ------------------------------------------------------- DATE '------=------- BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------=--------------DATE ---- -- --�-.------------------------------- ADDITIONAL COMMENTS ------------- ----------------------- ------------- ------------------------------ ------------------ --i`-�---------------------------------------------- ----------------------- ------------------------------------------------------1--_-_ ---- --- Del ------------------=----- - ------- -------------------------------------------------------------- by ------ --------------------------------------------------------------- ----- Date Inspection -_-------- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M