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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ---------- --- ------•------ (Complete in 'Triplicate) Z Data 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: / �y F-Gs• !i1/ -)-------�ENSU5 TRACT JOB ADDRESS/LOCA" N .�- w�l--� - i Owner's Name Phone AlAddress ---- G �------ --- - - --------- ------------ - City -;---------------- --------------------------------------- 1 � a Contractor's Name --------- .a.-d � License # ��- ��_ - Phone ------------------------------ Installation will serve: Residence N Apartment House'❑ Commercial ❑Trailer Court i❑ Motel ❑ Other -------------------------------------------- Number of living units:_------1_... 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 fl Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam Hardpan 1Z 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,) SEPTIC TANK' Size-_----_-_--___ ___ Liquid Depth --------------------------- Capacity ----------------- PACKAGE TREATMENT [ ] [ � ------------ ---------- - --'----- � Ca acit -- Type ------------------- Material---------------------- No. Compartments ------ ------- Distance ---------- --- YP Distance to nearest: Well ------------------------------------Foundation --------------------- Prop. Line -----_-------_------•- LEACHING LINE [k] No. of Lines ____-_I---------------- Length of each line---------L� .1)..... Tota! Length _!tiL_a_-,-----.-.-----_-- 'D' Box .--- Type Filter Material __+ _/ --------Depth Filter Material -----/y----------------------•------------ Distance to nearest: Well -----'Ya_1--------- Foundation -----1d_.------------ Property Line.-F---------------•--- SEEPAGE PIT [d Depth ._ S -------- Diameter ---__---- Number ----------1--------------- Rock Filled Yes ,K No . /�-: '- Water Table Depth -------- ----�p-------------------------Rock Size ----------- -------�-- - - Distance to nearest: Well -----------!p0_ __________________Foundation --------/_P------- Prop. Line ------------ REPAIR/ADDITION(Prev. Sanitation Permit x# ------------------------------------------ - Date ----------------------------------) Septic Tank (Specify Requirements) -------- - ---- ---------------------------------------------------------- Disposal Field (Specify Requirements) ________________ ----- -----------------------•--------------- ---------------------------------------------------- ------------------------------------------------------------------------------ ---------------------------------------------------- - -------------------- ----- ----------------------------- - (Draw existing and required addition on reverse side) + I hereby certify that 1 have prepared this application and that the work will be done in accordance with Son Joaquin I 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: "1 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 subject to Workman's Compensation laws of California." tSigned ---- ------ --------- --------------------- ---- -------------------- Owner Title -------------------•--------- -------- By ----- --(If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- - --------- - ------------------------- ---------------------------------- DATE _rr - _e0'J-------------------- BUILDING PERMIT ISSUED - ----------------- --------- ------------------DATE -------------•----------------------------- ADDITIONALCOMMENTS -------------------------- ----.--------------------------------------------------------=--------------------------- --------------------- ----------------------------------------------------------------------------------------------------- ------------------------------------- - --------------------------------------- ---------- --------------- ------------ ---- ------------------------------------------ ----------------- --------------------------- Final Inspection by: ----- - -------------------------------- ------------------------------------- SAN ----------- -- - --------------- -- -------- -- - - - - SAN JOAQUIN LOCAL HEALTH DISTRICT f E. H. 9 1-'68 Rev. 5M