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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ Permit No. ----- ------------------------------- .�T --------- - ----------------------- ----------------- (Complete in Triplicate) ------------- ------------------- ---- -=--------- - This Permit Expires 1 Year From Date issued Date Issued Application is hereby made to the'-San Joaquin Local Health District for a per 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/LOC/ANION ___�-� -- ---,--- -/_<___4-- ----- Owner's Name ----L�rr�---- ✓�'!'------- Phone ----------------------------------- Owners ------------ --- City Address , 17 ------------------------------- $ � License # 1 �r 'Phone Contractor's Name --- -------- ---- � 1 Installation will serve. Residenc ❑ Apartment House,❑ Commercial ❑Trailer Court 0 Motel ❑ Other Number of living units:------ Number of bedrooms _y___Garbage Grinder ------------ Lot Size -------------------------------------------- ----------- _______________ ________________-______- r I _________Private Water Supply: Public System and name ------------------------------ ------------------------------------------------------------- ; Character of soil to a depth of 3 feet: Sand:0 Silt[] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam:❑ i RK Adobe F] Fill Material ____---__.__ If yes,type ---------------------------- Hardpan (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.l V►' NEW INSTALLATION: (No septictankor seepage pit permitted if public sewer is available within 200 feet,) F PACKAGE TREATMENT [ 7 5EP7IC TANK'[` Size- _X -fes Liquid Depth -------------------------- ey Capacity �'O `T e _C�"`---�---f Material__ ------- No. Compartments -_c I--------------- r p Y � - YP Distance to nearest: Well _______----`-a----------------•Foundation r---____-- Prop. Line __,S_________..-.-- LEACHING LINE [r] No. of Lines -____.-------- Length of each line--__'__ �'6-`---------- Total Length --l'".-- ---------• .� De fih Filter Material ----- 1-1------- --- 'D' Box �--- Type Filter Material ------------------f p � -- , Distance Jb,nearest. Well -------1&--1------- Foundation ----------- Property Line _____---------------- *` ` SEEPAGE PIT [ Depth - __�=_S- -- Diameter __ `-fr_ Number -------- -- ---- ---- Rock Filled Yes No I Water Tcttiile"Depths-- Rock Size ------------------ __ Pro Line ---------------------- Distance to nearest: Well _____"_____�pd-------------------Foundation _________.__ ---- p. REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ------------------------------= ] , Septic Tank (Specify Requirements) ------------------------------------------------ ---------- ---------------- --------------- -------------------------------- - ---------------- Disposal Field (Specify Requirements) ------------- -- �-----=--- -- ---------------- - ----------- -----�--------- --------i---- ------------- - ' ----------------------------- --------------------------------------------- -- ----------------------------------------- _------------------------- ---------------------- - ------ t _________________ _ { [Draw existing and required addition on reverse side] I hereby certify that 1:have piepared this application and that the work will be done in accordance willi 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 California." Si sed --- --- -----�--- � Owner �� ' ---------- ---- ---------------------------f---------------- BY - --- -- --------- ---- --- ------------------------------- Title (if other than owner) FOR DEPARTMENT USE ONLY _ rDATE / r �-- APPLICATION ACCEPTED BY _ _ ______________ _ � " BUILDING PERMIT ISSUED ---------'-------------- ----• I ADDITIONAL COMMENTS ------------------------ -------------------------------------------------------------------------------------- -- ------------------------- -•--- ----- - ------------- I - ------- -�--------"----------------------------------------- ------------ SAN � - ------------------------------------ ---- ---- -------- Final Insp ectionbY: � - --------• -------- ------ -- SAN JOAQUIN LOCAL HEALTH DISTRICT t E. H. 9 1-'68 Rev. 5M