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FOR OFFICE USE: r ;,,\APPLICATION FOR"SANITATION PERMIT Permit No. Z _'� ... ----- ------------- ------ --- ------ ----- � -- ----- � (Complete in Triplicate) Date Issued ---- ---------- __ This Permit Expires I Year From Date Issued ------------------- " t Application is hereby made to the an Joaquin Local Health District: for a permit to construct and install the work herein described. This application is made incompliance with County Ordinance No. 549 and existing Rules and Regulations: r�7 �J----------------------------------CENSUS TRACT JOB ADDRESS/LOCATION ------- _L_/- - /�'-- -- - -- - -------- u _q - --Phone Owner's Name ------------------- --- Address _._ Z-- _ �.. - Q� ._�"'�' City -- ----------------- -yC� -� Contractor's Name -- ----------- -- ---- ------- -- -----�--�----------- - ---- --.License # -`-----:Sly- ---- Phone ---¢.�-- Installation will serve: Residence ❑ Apartment House,(]Commercial:❑Trailer Court l❑ Motel ❑Other _________ ------------- r Number of living units:----!-_----- Number of bedrooms'__------Garbage Grinder ------------ Lot Size -------__G - ---------Water Supply: Public System and name ------ -------------------------- ---------------------------------------- -------------------------------Private . Character of soil to a depth of 3 feet: Sand'❑,'..Silt❑ Clay ❑ •Peaf❑ Sandy Loam Clay Loam:E]7 i Hardpan ❑ Adobe❑ Fill Material ------------Af,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: tNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT f I SEPTIC TANK''![J Size------------------------------------------------ Liquid;Depth -----------------.-------- {.Capacity ---------------- Type--------------------- Material---------------------4 No. Compartments ----------------.. Distance to nearest: Well ------------------------------------Foundation ------------------------Prop. Line --;------------.------ LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---- -----------'_2 Total Length------------------------------- 'D' . - ----'--,-------------•--'D' Box -- ---- Type Filter Material ----- --------------- h Filter Material --------------------------------' " --------Dep t t f ---•-•----- Distance to nearest: Well _______,_--------------- Foundation ---------------------'=_-Property-Line -------------------------- SEEPAGE PIT [ ] Depth -- •Diameter _______________ Number _______.__.__-----____ __ Rock Filled Yes E] No 0- K� N, , Water Table Depth ----------------------------------- - Rbck S�ie'----------- ---------- - `�- Distance to nearest: Well ________________________________________Foundation ____.__y----------- Prop. Line ----------------- REPAIR/ADDITION(Prev. Sanitation)Permit e# --------------------'------------------------ Date ---------------------------------- Septic ------------Se tic Tank (Specify Requirements) ts) ------------- .-_-' _-------------- - -- --------_ --------------------------- <----------------------bisposal Field (Specify Requirements) 4 ------------ ------- -------------------------------------------- ------------- ----- ------------------------- --------------------------------------------- ------------- (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, acid 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." Signed -------------------------------- --------------- ----- Owner ` BY ------------------------------------ Title ----------- -- ---------- ------"------------ ---------- (If other t owner) FOR DEPARTMENT USE ONLY / APPLICATIONACCEPTED BY --------------------------- -�-------------------t---'-------------------------------------------. DATE _ 1-r` ---- ..................... , f':. BUILDING PERMIT ISSUED _:._ - =� - ----- DATE - - ----------------------------- ADDITIONAL COMMENTS _.--------- --------------------------- gl -. --------------------------•---------------------------------------- it ---------------------------______________ ---------- ------------------------------ �. > f � r,:�, y v. = Final Inspection b �_ Z- = _�- --------------------- ="------------------ -------------- -- -----.Date __ 1 f ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H. 9 1-'68 Rev. 5MY-