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FOR OFFICE USE' APPLICATION FOR SANITATION.PERMIT ---------- ------------------- -------------------- - t (Complete in Triplicate) Permit No. --------------- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein 3 described. This application is,made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .___ ;1 -41- -- - --------- ------------- ----- dC� - -- CENSUS TRACT ------ -------=------------ Owner's Name Phone 9 I Address City --- - --�---------------- ---------- - -------------------------- Contractor's ,+ ------...--- Name .P-±�, ----- -- - � - - -�•�-- -License# _ � ---- Phone ! Installation will serve: Residence Apartment House�0 Commercial:]Traile'r Court iQ Motel ❑Other Number of living units-----/__- Number of bedrooms__ar_. _Gorbage Grinder -----------_ Lot Size Water Supply: Public System and name _______________________ _ -----------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'[] Si It C] Clay ❑-``.Peat❑ Sandy Loam ,o Clay Loam Hardpan ❑ Adobe'E] 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,) PACKAGE TREATMENT [ ] SEPTIC TANK ) Size______________--------------------------------------------- Liquid Depth ------------..._ q Capacity -----=-------------- Type -------------------- Material---------------------- No.—Compartments Distance to nearest: Well ------------------------------------Foundation -------- ----- ---- prop. tine ...................... * a LEACHING LINE [ ] No. of Lines -------------_---------- 'Length of each line_______'" _____-- -- Total Length .____-_____ 'D' Box ------------ Type Filter Material ____________________Depth Filter Material ------------ ------------------.---- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. ----- ------------------- SEEPAGE PIT [ ] Depth ----- -------------- Diameter ________________ Number -___-_----_..___.__________. Rock Filled Yes ❑ No C] Water Table Depth ------------------------------------------------Rock Size ----- i Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................--- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------,--- ----_-_--) Septic Tank (Specify Requirements) �� i-�---------------- ` -=• --- ----- Disposal Field .(Specify Requirements) _- ---9 /401__ _-_�� v t ------- - --- ----------------------- f ------------ -W----- ----------- -- -- ----- ------ -----, _ -- 10 I ( raw existing and re uired dditi on reverse side) 1 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 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 become subject to Workman's Compensation laws of alifornia." Sign ------ ------- ------ _ n ------------------- w er ----- ----- - - --------- BY itle ..... ....... (if other than owner) FOR DEP T USE ONLY ` APPLICATION ACCEPTED BY ----------- --------- DATE -- O� BUILDING PERMIT ISSUED DATE . a -- ADDITIONAL COMMENTS } --------------------------------- - ----------------------------------- _ -------------------------- ------------------ _ _______________+t._.___ _ _ ----------- _._.______ ________________________________________ _ _ _ _ _ f�, - _ ._.__-_-____ Final Inspection by: -- --------Date "[ --- _ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M