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FOR OFFICE USE: ` \4, APPLICATION FOR SANITATION PERMIT / __ � --- ----- ------- ----- . ZP (Complete in Triplicate) Permit No ----- - ---- --------------------------------------------------------- ._...................................................... This Permit Expires 1 Year From bate 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 Mules and Regulations: p JOB ADDRESS/LOCATION ._ / _ __ -` _._ L--- - -- --/��'--� �-+�`-'- --4�r�'��`-G.�/..CENSUS TRACT --------------•----------- Owner's Name ._�... d' ----- ----- ---`-----Phone Address .-- ..----_ _ Cit Contractor's Name --- -�-----------------------------------License Installation will serve: Residence Apartment House-[] Commercial❑Trailer Court ',❑ Motel ❑ Other --------------------------------------------- Number -- -------------------- --------- Number of'.living units:-----/--_ Number of bedrooms ---`T�___----Garbage Grinder,VA— Lot Size --r___-----_ Water Supply: Public System and name ----------------- -------------L.--------------------------------------------- ---------------------------Private X Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} O PACKAGE TREATMENT SEPTIC TANK'[ ] `i- -Si'te-----------R---------_------------------------ Liquid Depth __________________________ Capdcity -------------------- Type --------------=1 Material---------------------- No. Compartments ------ -----------•--- F Distarice to nearest: Well _ ------ ------------_-----Foundation ---------------------- Prop. Line -------------:-------- �f LEACHING LINE `[ j No, of Lines _ Length of each line____________________________ Tota! Length _.-__-______._..___.__.____ V 'D' Box -------------- Type Filter Material --------------------Depth Filter Material ---------- --------------------------------- .o .A ance�'for nearest:,Well ------------------------ Foundation ------------------------ Property Line ------------------------ SEEPAGE PIT [ ] Depth,, ---------------- Diameter. ---------------- Number---------------------------- Rock Filled Yes ❑ No i❑ Water Table.Depth-'--'%-- "- •--:;mock!.Size ----------------------------- -- Distance to nearest: Welk. ---------------------- ------Foundation -------------------- Prop. Line .---------------__---- REPAIR/ADDITION(Preva Sanitation Permit* ------ -:------'---------------------------- Date ------.---------------------------} Septic Tank {Specify Requirements} T-- --------------- - Disposal Field (Speci R quirement ----- ""-- ----------- (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 ficen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compefrnsathm laws of California." Signed -------- ------ ------- --------------- - ---- Owner By ----- --= _ Title ---- ------------------------- (If oth an ovrner) r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------------- --------------- DATE ----------------- BUILDING PERMIT ISSUED ----..--`--- ---DATE ------------------------ --- ----------------------------------------------------------------- ------------------- ADDITIONALCOMMENTS-----------1.'----------------------------------------------------------- -------------- --------------- --------------------------------------------------- i --------- ------------ ---------------- " ' ------------ --------------------------------- Final Inspection b _------_---Date __ _ Z-J ___ _________ _.--__ --------- - - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1"68 Rev!:SM