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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No: . --. %6y --------------------------------------------------------- --------------- This Permit Expires ! Year From Date Issued Hate 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 �---�--- --- ----------------------------------------------- -------- CENSUS TRACT Owner's Name .... ---- -- --- --------------- -------- ---- dhone -- - -- Address / �- r -.- - City i `----------------------------•--•- - +f Contractor's Name ----- -..J--- ---- ------------- ---.License # f_� 3 Phone ---------------------------•-- Installation will serve: Residence Apartment House�❑ Commercial'-[]Trailer Court i❑ Motel ❑Other Number of living units:---._- __.- Number of bedrooms 4�----Garbage Grinder --------- -- Lot Size ------- -------------- ------- --------.--- Water Supply: Public System and name`--------------------------------•---------------------------------------------------- ---------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Ciay Loam ❑ Hardpan [j Adobe [ Fill Material -----_---- If yes,type --------------------------_ i# t (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,), \i PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------ -- --------- Liquid Depth --------------------,- _ 4 Capacity ---------- --------- Type -------------------- Material-- ------------------- No. Compartments Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------- ------ LEACHING LINE [ ] No. of Lines ------------------------ Length of each line_-_-----.--------_-_----__ Tota! Length ---------------. .---------- 'D' - -- ----'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------- ----------------------- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. ------------------------- 1 SEEPAGE PIT [ ) Depth _------------------ Diameter ----------- Number -- -------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------ -----:----__Rock Size -------------------------------- ;�- Distance to nearest: Well ----------------------------------------Foundation -------------.------ Prop. Line ---------------.------ REPAIR/ADDITION(Prev. Sanitation Permit#--------- ----------------------------------- Date ----------------------------------} Septic Tank (Specify Requirements)-',------- -------------------- -----------------------------------------------------•----------------------------_ Disposal Field {Specify Requirement ) --- - --_---- --- _-_-- ----- - --------------- -- ------- T -- ----------------- ---- ------ - ----------- -------------------------------------------------- ----------------- ---------------------------- (Draw.existing and required.addition on reverse side) fl I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin j 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 b subject to Workman's Compensation laws of California." s Signed ----- x s --------------. Owner', BY ----- -- L a - - - ---------- +�.�----------------- +---------- Title --I ' (If other than owner) , 111 FOR DEPARTMENT USE ONLY QQ APPLICATION ACCEPTED BY DATE "' � L BUILDING PERMIT ISSUED --- --------------------- --------------------------- --------------------------DATE ------- ---------------------------- ADDITIONAL COMMENTS ----------------- ----------------------------------------------------------------------------- ------------ --------------------- -------------------- -------------- ----------- ---- ---- -- ---- ---- --- ------ - - - - ---- Final Inspection by: - ----------- -----------------------------------------------------.Date _/ 9 SAN JOAQUIIV LOCAL HEALTH DISTRICT ' E. H, 9 7-'68 Rev. 5M