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_ .. oR OFFICE USE: � APPLICATION FOR SANITATION PERMIT �j Permit No. �� _c (Complete in Triplicate) ---------------------------------- ----------------- -- -- Date 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: ' G� ----CENSUS TRACT -------------------------- JOB ADDRESS/LOCATION Phone �-� +- �------ 5 R- • ..Cit- ---------- Owner's Nome ----------------- Address ------------ ------ one�6�� 9 ------- Contractor's Name --------------- --. --- -- Lxnse t installation will serve: Residence�gApartment House°❑ Commercial []Trailer Court i❑ Motel ❑ Other -------------------------------------------- Number ------------------------------------------Number of living units:------L____ Number of bedrooms -------- _Garbage Grinder ------------ Lot Size --X-- - -------- Water Supply: Public System and name -------------------------------------------------------------- - ----------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt ElClay ❑ Peat E] Sandy Loam Clay Loam EJ 4 f Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- 3 L :. s i (Plot plan,-showing size of lot, location of system in relation to wells, buildings, etch must be placed on reverse side.) r^ NEW INSTALLATION:-- - (No-septic tank:�or seepage pit permitted•if,public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth ------------------------- W Capacity -------------------- Material---------------------- No. Compartments ----------.---------.-- Distance to nearest: Well ------------- - - --------Foundation -_- ------------ Prop. Line ---------------------- LEACH ING-UNE No. of Lines ------------------- ---- Length of each 'line------------------------- Total Length -----------•-------------- 'D' Box -___.____--- Type Filter Material _____-_"_ ------Depth Filter Material ___'`_t----- --------�--�--=-------- t • , .- Foundation - -------- Property-Ain6 ---------`:--_---- - Distance to nearest:-Weld ________________. ` `" -______ Rock Filled 'Yes No ❑ SEEPAGE PIT).[ ] j Depth ---f------------ Diameter ------------ - Number ❑ j Water Table Depth -------------------------- ' ` Rock Size ---- R Distance to nearest: Well --------------------------------- : -__.Foundation ---'----'''-- ------ Prop. Littre -•------•----••------- . REPAIR/ADDITION(Prev. Sanitation rPermit# _ ` °-=---- -- = Dates U = ------------------------ = ) e � s - Septic Tank (Specify Requirements) ----------------------------- i y ______"__________-"____________ _____________ Disposal Field (Specify Requirements) --------- - -- 1 u l ( +f --------------------------- ________________"F _.— --___.______-__"_ to ' ____I__.__ __- ___.___.____"______________________�-________--_____________-__________--________________----________-___________- � (Draw existing and required addition on reverse side) 1 i 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. Sari Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: f "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 become subject to Workman's Compensation laws•,"ofVCalifornio."r ,--_ i Signed --------- -- - ------------------------ Owner --- Title (If other t owner) k FOR DEPARTMENT'USE ONLY ry--tel/ APPLICATION ACCEPTED BY --------------- ----- ------------------------------------------------ DATE ------ - - - ------------- ------------------------- BUILDING PERMIT ISSUED �' DA -:.,.------------------------ ----------- ADDITIONAL COMMENTS _- -- - ----- ---- ------- ¢ ,4. _ _ ---- - - ----- � l�X: -`---�---f -� - -- '------ ------------------------- ------------------------------------------------------------------------------- F - - - --------------------------------------------- ---------------------------------------------------- --------- ------------------------------------------------------------------------- - - -- Final Inspection b ------------- -----------------Date _". - - !?_' r----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M