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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: ��-- ---- ------- ------- -------------------- ----------- (Complete in Triplicate) -- -------------------- ---------- -------------------------------------------------- - --- This Permit Expires 1 Year Frain Date Issue 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 mal in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ; -_ _I-r--�"-- '-- A "' j--------------------------------- CENSUS TRACT { 0 Phone ---------------------------------- Owner's Name ._--__ ' _, l 5 city -------------------- Address ------------C1 --�� / ----- - - , --------- Contractor's Name ---- ---- �---`�`----- - - --------- ---------License #��3 ---y--- Phone --------------•------ Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court l❑ Motel ❑Other -------------------------------------------- Number of living,units:_.______ _ Number of bedrooms -"-----Garbage Grinder -__._"__-___ Lot Size --------------- ---------------------------_ _ ff. Private,' Water Supply: Public System and name ------------------------------------ 4 Character of soil to a depth of 3 feet: Sand' Silt-0 Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ p Material ------------ if yes, type --------------------------- Hard an Adobe'❑� Fill Ma#ert I a buildings;-etc. must be placed on reverse side.) {Plot plan, showing size of lot, vocation.of syste`m'in relation to wells, _ h f NEW INSTALLATION: (No septic tank-or seepage pit permitted if public sewer is available within 200 feet,] ' ! " _ Liquid Depth ------------------- ------ 1 PACKAGE TREATMENT [_�.. SEPTIC WANK'[ I Size-------------------------- -------- ------ iq p ' No, Com artments ............. t Capacity: - Type ------------- Material p [ -- ---------------------- ------ ___.-_:_ _ :Foundation----------------------- Prop. Line ---------•---------•-- Distance to nearest: We'll - LEACHING LINE [ ] ' No. of -Lines ----- - - , ,Length of,,each line= :'_.-==------ Tota! Length ------- y , Type Filter Material _- ---]-Depth Filter Material ---------------------------- ------------ --------- , D' Box ' ------- Foundation ------ ---------- - Property Line ---------------------- Distance�to nearest: Well _____________ __ .. . SEEPAGE PIT [ ] - Depth=� �__.--__ Diameter-~_--�_--------- Number- - ,:::__�_- = Rock Filled Yes [] No I❑ Water Table Depth F_-____------ Rock Size ""----------------- ----- -------- ----- Pro Line ------...._.----- Disfiance�to nearest: Well ------------------------------------I---Foundation � P- r� -•-- v REPAIR } V Date --------•- (ADDITION(Prev. Sanitation Permit# .------•- - _ Septic Tank (Specify Requirements) -------------------- r --------------------------------------'---------------------------------------------- Disposal f=ield (Specify Requirements) ------------------- - — r- IIAL"_- ----�---- � - r---' - ---��,r��----I--------- ------------ ------------------------------------------------- --- -�-- _- Q C p p ------- ------------------------------------ (Drawexisting and required ad itio on reverse e I hereby certify that I have prepared this application and that the work will be done in accordance 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed -------------------- ) ------------------ Owner -------------------------------------- ------------------------------- ---- ------- (If ____(If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - �_- ----------------------------- DATE - -- - -- ---- ------------------ BUILDINGPERMIT ISSUED -- ----------------------------------------------------------------------------- ADDITIONALCOMMENTS ------- --------------------- --------------------------------------------------------------------------------------- ----- -------------------------------------------------------- ------------------------------------------------- ----- - - -- ---- ------------------Date ------ Final Inspection by: _ ----- zT SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M