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FOR OFFICE USE: riPPLICATION FOR SANITATION PE T Permit No. - --------------- ` ------------------"--I (Complete in Triplicate) _ - p Date Issued --------��!_ This Permit Ex ires 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. ------CENSUS TRACT -------------------------- JOB ADDRESS/LOCATION ._. - � �� ---- { -------------Phone ------ Ix Owner's Name ----- - ----- -- ---- ---- - - - , Address ------------------ ' ---- #_ ---- - City - - - ----------------- Address --- --- --------- ---- _ GG Contractor's Name - -e----.License # 1fi -2-1Phone ---------------------- ----- Installation will serve: Residence Apartment House'❑ Commerc;al ❑Trailer Court ;❑ � Motel ❑ Other <� - k -- - Number of living units:_____ _.____ Number of bedrooms ------------Garbage Grinder _---------- Lot Size _------- Priv--------- r-iv---ate--- - Water Supply: Public System and name ---------------------_______-___-- ------ Character of soil to a depth of 3 feet: Sand'❑ ilt E] Clay 0 Peat❑ Sandy Loam -❑ Clay Loom '[:] „k Hardpan Adobe F-1 Fill Material _-----____-If yes, type ------------------- I must be placed on reverse side.} {PI'ot plan, showing size of lot, location of system in relation to wells, buildings, etc. NEW INSTALLATION: (No septic tank or, s epage pit permitted if public sewer is available within 200 feet__ ,} SEPTIC TANK [ ] Size ---•------------------- _ Liquid Dept PACKAGE TREATMENT [ I ---------------- Compartments Material---------------------- No. Com _____.---------- . Capacity l-- � '`-'---- ---- Type -------------------- Distance to nearest: Well --------------------- --------------Foundation --------------------- Prop. Line _--------------------- (^—` #" Total Length Length of each line -------------------------- ----------- ---------------- LEACHING ------ --,---------------- LEACHING LINE [ ] No. of Lines _-___.------------- g r - Depth Filter Material ---------------------------------- ------ �'D' Box ,- ---__"-----. Type Filter Material -------------------- - 1)N + _ Distance-to nearest: Well ------------------------ Foundation ---:-------------------- Property Line ' __ Number ___..__ Rock Filled Yes ❑ No ❑ SEEPAGE PIT [ ] p _-- Diameter - ----- ------- - Z Depth --- --------- - --- ---------- -- I r Table Depth Rock Size --------------------------- 'Water .I -------------•Foundation -------------------- Prop. Line -------------- ------- Distanceto nearest: Well ____________________ ___ _ > `Y L REPAIR/ADDITION(Prev. Sanitation Permit T Septic Tank (Specify Requirements) - - -- ----------------- --- -- = a ----- ' bisposa! Field IS Requirements) ---,a- ! fr ..._ ----------------------------------------------------------------------------------- -------- c-+ W --------- --------------- ----------- --------------------- ----------- j -- with San Joaquin ------~---------.------- ----------------------- --- - �s �_ -•� (Draw existing and required addition on reverse side} e.. l��lnereby certify that I' have prepared this application and that the work will be done in accordance County ordinances, Staff Laws, and Mules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed'agents signature certifies the following: r 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 becomes ject ta'Workma 's Compensation laws of California." ----------- Owner Signed - -- - ------ - ----------- ------------ ------ _ '" ------------ ---•---- --------- ------ Title ----- -- --�--- (if other than owner} ,� , , FOR DEPARTMENT!USE ONLY APPLICATION ACCEPTED BY _-- ------ - - --- ---- DATE ._r.�" �f ------------------- - ------------ DATE _..�---------------------------------- -------- ------- ------- -------- ----•--- BUILDWG PERMIT ISSUED -------------------------- ----------------------------- ADDITIONAL COMMENTS -------- --------- -- -- -- ----------------------------------- - ------------ -------------------------------------- ---------------------------------- ------------------- - -------------------- ------ _----------------------------------------------------------- -- ----=•------ ._y_ ---- - ------Date ----------------- ---------------------------------- - - --------Final Ins ection b SAN JOAQUIN LOCAL HEALTH DISTRICT E. H: 9 1 '68 Rev.