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OR OFFICE USE: J APPLICATION FOR SANITATION PERMIT Permit No. (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: JOB ADDRESS/LOCATION .------ ----------------------------------------------- ----- ---------C NSUS TRACT -------------------------- f� - Phone _ . �3" -_,D-6- Owner's Name �_, .) � ; i �✓-�?.�Q � Address � ------- --�------- � �-- ------------------ - Cit -------------------------------------- Contractor's ------------ ---- ----- - ------Contractor's Name ------4)_i -----------------=--------License # ------------------------ Phone Installation will serve: Residence Apartment House-[:] Commercial [:]Trailer Court ;❑ Motel ❑ Other ---------��-----��-- ------------------------- Number of living units:------l__-- Number of bedrooms _--____r? arbage Grinder ------------ Lot Size Aetgo�c;- ---------•••- Water Supply: Public System and name ------------------- -- --------•----------------------------------------------------------------------•------Private Character of soil to a depth of 3 feet: Sand'p Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam El Hardpan ❑ Adobe ❑ Fill Material ------------- If yes,type -----____------------------- (Plot ___________ --(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,) N. PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size__ -y --� Liquid Depth __!�___________________ Vj 3 � � Capacity _l '�1____ Type ` ''-'►Material_C 'L+l Compartments ---------------------- Distance to nearest: Well ____=____ L,c_______________Foundation�__.l -_--__---_ Prop. Lirfe -_____-- LEACHING LINE [ ] No. of Lines -------�- --------- Length of each Hne------ ,� "'"" Total Length ----------- LEACHING 'D' Box ------------ Type Filter Material __L'_h�_Depth Filter Material _--_ --------------------------- Distance to nearest: Well ------------------------ Foundation --------------- ------ Property Line --------------------••-- SEEPAGE PIT [ ] Depth -------------------- Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------..---------.- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) _ Septic Tank (Specify Requirements) ------------------------------------ ----------------------- -----------------•---------------------------------------------------------- DisposalField {Specify Requirements] ------------- ------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------- •---------- ------------------------------------- ----------------------------------- ------------------------------------------------------------------------------------------------------------------------- (Draw - -------------------------------------------------------------------------------------------------------------------------------(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 accordpnce 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: "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 - Q- ------- Title ------------------- -- ------------------------------------------------- I h (If other than owner] FOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY �' ---------------------------------- ----------------- DATE _. ----------------- ---------------- BUILDING PERMIT ISSUED -------- --------------------- ----------- --- -------------------- ----------------------- - -----DATE ------------------------------------------- - ADDITIONALCOMMENTS ---------- ------------------------------------- ----------------------------------------------------------------------------- --------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------- ---------------------------------------------- - - -- - - - - - -- -- -- Final Inspection by: --------- Date --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M