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r FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) ?ermit No. - ____ This Permit Expires 1 Year From Date Issued 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/LOCATI �y --- ,---G- 474.f-IAy e.�-------------�1� ,--------CENSUS TRACT�"��-�----- Owner's Name F ----------------------------------------------- --------------------------Phone ------------------------------------ Address -------------- 2�3-- --- - City- -- Contractor's Name d// L - = s.�t a - .License # ------------------------ Phone -----------------------_-... Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court :E]Motel E]Other ,� ,a Number of living units:-- .__ Number of bedrooms _ _---Garbage Grinder ________ Lot Size _________________________________ __________ Water Supply: Public System and name ---------------------------------------------------------------- ----..--Y-----------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat[] Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Moterial ____________ If yes,type _________.____-------------- (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 pubtic.�sewer is available within 200 feet,) \` PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size---------------------------------_------------ Liquid Depth -------------------------- Capacity --------- Type -------------------- -Materials----------- --------- No. Compartments ---------------------- I Distance to nearest: Welt ------------------------------------Foundation ---------------------- Prop. Line ---------------------- LEACHING LINE [ j 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 PIT [ ] Depth ____________________ Diameter _____________Number -------------------- ----.-. Rock Filled Yes ❑ No C] Water Table Depth ------------------------------------------------Rock Size __.----------------------------- Distance to nearest: Well Foundation -------------------- Prop. Line ________________.____. REPAIR/ADDITION(Prev. Sanitation Permit# -------•------------------------------------ Date ----------------------------------) Septic Tank (Specify Requirements) --------------- .� --- ------------------------------ - e-- ------------------------------ Disposal Field [Specify Requirements] _ __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 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_or which this permit is issued, I shall not employ any person in such manner as to become su Iect rkman's;Compensation.laws of California." Signed Owner BY --- ------------------------------------- - ---------------------------- ------ -Titl'e----------- ----- (If other than owner) R EPARTMENT USE ONLY APPLICATION ACCEPTED BY _ ----------------------------------- ----- DATE -----� ------ -- --- -- -------- BUILDING PERMIT ISSUED ------`""»-------------- ---------------------.--------------------------------DATE ------------------------------------------- ADDITIONAL COMMENTS ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------I------------------ ------------------------------------------------------------------------------------------------------------- ----------- ----- -------------------------------------- --------------------------------------------------------------------- Final Inspection by ----- ---------------- Date .......---- --------- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M