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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ------------------ (Complete in Triplicate) --------------------------------- Date Issued ---6-1 - ------------- 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: ! 7-/-----e5Z - ENSUS TRACT -------------- ----------- JOB ADDRESSfLOCAT Phone Owner's Name ------ , 0 Address --------- r - - - ------ -- ----------------- City - --- -- - - - -- . , _-. -- Contractor's Name -------- __ ___ -- -�--'-•=_----- -.License # _�-�.�- ---�--- Phone --------------------•-- Installation will serve: Resident Apartment House❑ Commercial ❑Trailer Court l❑ Motel ❑Other --------------------------- ---------------- ot Size Number of living units -- Number of bedrooms �-_----Garbage Grinder ------------ L -_-------- - --- ------------- Private Water Supply: Public System and name --- ------{------------------------------------------------------•-------- -------- I Character of soil to a depth of 3 feet: Sand's Silt.O Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ l Hardpan ❑ Adobe M Fill Material ------------ If yes,type ------.-------•-------- - must be placed on reverse side.) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Q SEPTIC TANK [ ] Size----------------------------------- ------------ Liquid Depth ------#-------------- TREATMENT PACKAGE { l Capacity -------------------- Type -------------------- Material-------------------- No. Compartments Distance to nearest: Well ___________ I` ----------------------- -Foundation ---------------------- Prop. Line ---------------------- Length of each line---------------------------- Total Length ------------ j LEACHING LINE [ ] No, of Lines ------------------------ 9 1 ilter Material ---------------- ___.Dep Depth Filter Material ____-_____ ___ ;. Type F Property,a Line- --------•--------------• Distance to nearest: Well ________________________ Foundation _____-------------- --- p Rock Filled Yes No i❑ i SEEPAGE PIT [ ] Depth-----------------g- Diameter ---------------- Number ------------------------- ❑ Water Table Depth ------- ------------Rock Size --- ---------------------------- 4 } Li _.......--•••- ....... I Distance to nearest: Well'------------------- ---------------------Foundation --------- -- Prop. ne R. REPAIR/ADDITION(Prev. Sanitation Permit� -------.-------- ------- = - --------- ----- Date ----- •-------------------•- -----) .& Septic Tank (Specify Requirements) --------�---------- --------------------------------------------------• --------------------- Dis oso Fi Id (S ecify Requirements) ------------- -- --------- ----- -- ------ - - --- - ----------------- I . -- - ----- . -----44 l (Draw existing and required additio on reverse side) r I hereby certify that i have prepared this application and that the work will be done in accordance with' San Jia, uin 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: p not employ any person in such manner "I certifythat in the performance of the work for which this permit is issued, I shall as to become subject to 's Compensation laws of California." Signed ------------------------------- -- ------ ----------- Owner By ------------------ --- - - ------ Title ---- --- -------------------_-------------------- (If other th caner) FOR DEPA TMENT USE ONLY APPLICATION ACCEPTED BY ---- �.�. ----------------------------- DATE ` BUILDING PERMIT ISSUED --.------- D --- -------------•-- ----------------------------------------- ADDITIONAL COMMENTS ________ _________ --------------------------- ------ --------------------------------------------------------- --------------------------------------------------------•--- ---------- ----------------------- - ------------------------------------------------------ ------- Date y Final Inspection b y SAN OAQUIN LOCAL HEALTH DISTRICT ----------- -- E. H. 9 1-'68 Rev. 5M x 'f