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FOR OFFICE USE APPLICATION FOR SANITATION PERMIT ------------ --------------- (Complete in Triplicate) Permit No. ---------- --------------- J This Permit Ex ares 1 Year icrom Date Issued p' Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work h described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: herein JOB ADDRESS/LOCATION ._-Z'1 �` /'� � -2�, ?"/f,- A !" la/� _. _ 0,CENSUS TRACT _s_�I__j,- Owner's Name " lam - - __._.----" e Address --------- - - --- ----_-- --Phone=---- - �------------- ------------.._. City Contractor's Name ._- .- - '- --------------------- _ •___- i 4---------------------------License # �n. - Phone '.' Installation will serve: Residence;'ApartmentHouse❑ Commercial❑Trailer Court ;❑ Motel ❑Other ---- _y Number of living units:______-_--- Number of bedrooms _�____Garba e Grinder Water Supply: Public System and name _____" g Lot Size ;2--- � � ---------------------- Private k --------------- -- ---- ___ _______________________ ___ _ ___ C aracter of sol! to a depth of 3 feet: Sand❑ Silt C(a ❑ Y ❑ Peat❑ Sandy Loam ❑ Clay loam ❑ Hardpan ❑ Adobe X Fill Material ------ ----- If yes,t (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 Candor seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK' [ Size- ------ ----- Liquid Depth Capacity P Y Type ----------- Material---------------------- No. Compartments Distance to nearest: Well ------------- -""------""--'"---'_•" --- --- ---•---------Foundation ---------------------- Prop. Line ----------- LEACHING LINE No. of Lines'.__,"-_- _-___- "_-__ Length of each line -------__ Total Length D' Box __-- ---------------------------- ------4 Type Filter Material _________________--Depth Filter Material - ------•------------------------ Distance to nearest; Well _______________________ Foundation _____________- SEEPAGE PIT ------ Property Line --------•--------------- [ l Depth --------`---------- Diameter ---------------- Number- ---------------------------- Rock Filled Yes ❑ No �, Water Table Depth �----------- - ------- -------Rock Size Distance to nearest: Well ____________________ -•__Foundation ' ----- Prop. Line ----------- ---------- ----------------------------------------- -- -- ------------- _ PAIR/ADDITION(Prev. Sanitation Permit # _______________________ • --------------- ----- Date -------"---------•- Septic Tank (Specify Requirements)------------------_------------ _ -------------- -- bis -- ---- • ---- ------------- al Field (Specify Requirements) ---- d - `w W . _ ------------------ ------------------------------- ------_ - - �- ---------------- ----------------- ----------- _ ------------------------------- ' (Draw existing and required addition on reverse_side} ! 1 hereby certify that'I have prepared this application and that the work will be done in accordance with San Joaquin 1 County Ordinances,•State.laws, andRules-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 California." Signed --- --------------- . - -- --- ------ -------- Owner - - ---- --------------------------- BY --- (I - - _ . ------ t Title (If an owner) ---- 'XOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. BUILDING PERMIT ISSUED DATE ADDITIONAL COMMENTS -------- ----------------- -------- ---DATE -------------- ---------------------------------------------------- ---------------------------- ------ ------- - �_�.r Final Inspection by: -_ --------------- ------------ � - --- --- - ------ --------Date - r �- SAN JOAQUIN 'LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev:5M-