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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. --------------------- ----- (Complete in Triplicate) //- / f Date Issued "____________ ------------------ ------ --_----- ------------------" 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 with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION -- -.� - '='rte ---------------------- ----CENSUS TRACT -------------- ----------- Owner's Name -------- - Phone 7t/sU ------ - ---- - Address City / ---------- Contractor's Name ______ -_. ____ _--_ __ _ __ __-�- - -- License # _�YT3.F1---- Phone Installation will serve: , Residence Apartment House❑ Commercial ❑Trailer Court l❑ [ Motel ❑Other -------------------------------------------- l Number of living units-------- Number of bedrooms -_____Garbage Grinder ____________ Lot Size ____________________"___________-_____ ___ Water Supply: Public System and name -------------------------- ---------------------------------------------------- ---------------- Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ C y ❑ Peat❑ Sandy Loam -❑ Clay Loam 0 a Hardpan ❑ Adobe Fill Material ------------ If yes, type ______________________---- (Plot plan, showing size `of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) p� NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) t�1 PACKAGE TREATMENT [11 SEPTIC TANK [ ] -- — - Size__ ---w----`----------------------------- Liquid Depth ------------------------•- ------ T e -------------------- Material------- ------------- No. Compartments ---------------------- Capacity -------- - Yp Distance to nearest: Well ------------------------------------Foundation.---- ---------- Prop. Line ---------------------- LEACHING LINE [ I No. of Lines ------------------------ Length of each line____________________________ Total Length -___-__.___-____--_-_____... 1 DBox ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- Distance to nearest: Well ________________________ Foundation --------------------.--- Property line. _____..._______-__._.... SEEPAGE PIT [ j Depth __________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ t Water Table Depth ------------------------------------------------Rock Size ---------------•4 --------- r Distance to nearest: Well ------------------- - ------------------Foundation _---______.____._"__ Prop. Line _...______-_____.__... REPAIR/ADDITION(Prev. Sanitation Permit e# ------------------------------------------- Date ------------------•---------------) Septic Tank (Specify Requirements) ------------------- ---- -------------------------------------- ------------------------------ -------------•---------- Disposal � FieldAle,�:.fyRe. irements) - fit------- --� ---- -- - � - ----- -'-s--""-" -"-' -"-------""- ------------------------------------- ---------------- - --= -------------- -- --------- --------------------------------------------------------------------------------------- (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 subjec Workman's Compens t laws of California." Signed ------------------- ---`------ ------------ - -- --- - -- -- - ------------------ Owner ----- Title " ---------------------------- (if other t an owner) F T FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY • =� � r - --- -. DATE _ _ -y_- '-' � �'F�---------------- BUILDING PERMIT ISSUED ------- --------------------- - -------------------------------------- -----DATE _.-----------------------------•-•--------- ----------------------- ADDITIONALCOMMENTS ---------------- ----------------------- - -- 1----------------------------------------------------------------- --------------=--------------------------- ---------- ----------------- I- --- -------------,--------------------------------------------------- - _ - ------------ ---------------------------------------------------------------------------------�-�-------- ----------------- ------------------ _____________________________"--._ ___- -- Final Inspection by. 1 Da#ej SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M