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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------------------------- - (Complete in Triplicate) Permit No. lqwV\T Date Issued -----------------------------------------_--------_------ This Permit Expires 1 Year From Date Issued Application is hereby made to the Sdn•Joaquin Local Health. District for a permit to construct and install the work herein described. This application is made`incompliance•-m;1th•�Co6nty Ordinance No. 549 and existing Rules and Regulations: JOB .ADDRESS/LOCATIO �:7_ //;#f? �______ '- � CENSUS TRACT __________________________Owner's Name ---------7- ------------- -------- ---- - --------------- Phone._. _2__--- 7�.�------ Address `�: : `•' � �'�� City ---------- ------------•--•-•--•------- - - - a Contractor's Name --- - -------------------------License #)oi-,> Phone p-- �a7--- -- l Installation will serve. Residence N!Apartment-House��❑-Commercial{]Trailer Court ❑ Motel ❑Other E -------------------------------------------- L' edrooms ____ __Garbage Grinder of living units:_-- __.- Number of,b _ _ LotSizet y __ ._y _._ �rWater Supply: Public System and name _____________________.____---------------------------------------__ _________________Private ❑ Character of soil to a depth of 3 feet: Sand'E] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑+ Clay Loam 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.) N NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -------------------------- Capacity --------------------.----- r P Y ------------ TYPe ---------------- -- Mater..—,:.,- - - Ca acit -ria Type No. Compartments ______________________ Distance to nearest::+Well ____Foundation ___.___________'_._-_ Prop. Line ______________________ t [ l g --------- Total Length LEACHING LINE No. of Lines ----_;------------------- Len' th `of each line-------_----_`__-- - �- D' Box ------------ Type Filter Material`-------------Depth Filter Material --------------•---_-------------.----- --.- ~ Distance to nearest: Well --------------�V-_.___ Foundation ------------------------ Property Line __-____._-.-.._._.------ 1 3 S SEEPAGE PIT [ ] Depth _------ ------------ Diameter ------__.___-�__ Number ---------------------------- Rock Filled Yes ❑ No ❑ f Water Table Depth ' ------------------------------ --------Rock Size -- t----------------= jDistance to nearest: Well ______________________ ________________Foundation ------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------- >_________'___ Date ------------ -_------------------ Septic Tank (Specify Requirements} -------------- ,� I 1 Disposal Field (Specify Requirements) --__- r ------- x ------- ---------- ------------------------ ---- --- - - a .��,. (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 y 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: 11 "I certify that in the performance of the work for whicWthis„permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California.” f Signed --`= = -_ -----_= �----------------- ,-- B � -------------------------- other an owner} FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ------ - ---------------------------------------------• DATE ] OI-721-------------------- BUILDING-PERMIT ISSUED ------ - --------------------------------------`Y ....DATE ------------------------------------------- ADDITIONAL OMM S -_ �='__ - - --------------------------------------------- --- - ---------- --- --� � - meq.--7 z-- --- ------------------- ------- ► tti .,r- - ------------------------------- ---------- - _r -- Final inspection b ` r`: p Y = - = ----------- Date 1 7/ SAN JOAQUIN LOCAL HEALTH DISTRICT 6 E. H:9 1-'48 Rev. 5M