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FOR OFFICE USE: ^- APPLICATION FOR SANITATION PERMIT `ff - -- --------- ------------------------------------ ..- - -Yy )Complete in Triplicate) Permit No: ---------- --------------------------- ' This P mit Expires 1 Year From Date Issued 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 . ®, .. CENSUS TRACT -------------------------- e Owner's Name ------------ -- ----------------Phone'--.- Address ------------ --- -------------= ----- = CitYT �, rrll `` `� Contractor's Name --- ---- --5- ---------- ----------------Licen.'se # ---------.-------------- Phone ..--.- 4"?(� --- Installation will serve: ResidencetR�Apartment House❑ Commercial ❑Trailer Court ',❑ Motel ❑ Other -------- ----(------------------------------ - Number of living units:----!__---- Number of bedrooms ___.Garbage Grinder ------------ Lot Size ____________________________________________ Water Supply: Public System and. name --------------- -----------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ z_ Hardpan ❑ 'Adobe%y. Fill Material ------------ If yes,type ---------___________________ (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,] I PACKAGE TREATMENT ( ] SEPTIC TANK [ I Sized.______________-__:____---------------------- Liquid Depth ___. _-__.____________..-_ Capacity ------------- ---------Type --------- ------ +------- Material---------------------- No. Compartments ----------- - -=---- Distance to nearest: Well -- --------------------------------Foundation ---------------------- Prop. Line ---------_._.._,.--•-- LEACHING LINE [ ] No. of Lines---__=--.-------- ------ Length of each line----------------------- ---- Total Length ------------------- -------- V Box ------------ Type.Filter Material --------------------Depth Filter Material -------------------- ---_- Distance to rfearest"W II--- '-- -------- ----Focindation ------------------------ Property Line ------------------.-.. SEEPAGE PIT [ ] Depth '----=-------------- Diameter --------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ----=-------------------------------- -------Rock Size -------- --------------•---:-----`' Distance to nearest: Well ____-_.__________-__________________Foundation -------------------- Prop. Line _______.__.........._. REPAIR/ADDITION(Prev. Sanitation Permit# ------------- ________________-._.__._ --- Date ____-_____-____________ Septic Tank (Specify Requirements) -- - =----- - - Disposal Field (Specify Requirements) �� °__ � ----------------------- - ----- -------------- -- ------- -- ----------------- " ----------------------------- --------------------------------------------- ------ ---------------------------------------------------= ------------ ------------------- ------------------------------------------- ---------------------------------------------- f (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 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: - "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such mariner as to become subject to Workman's Compensation ilaws of California." Signed ------------- -------- _a_ - r Owner B ----- -------------- ---- - Title ---- ----- ----- ----s- ----- --------------------------------------- (If oth an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------------- --�-V z -------------------------------------------- ------------------ DATE -_r Z-D-� 41l BUILDING PERMIT ISSUED _'�-------------------- - ------4-----------=-----------------------------------------------;----------- --BATE---------.------------------------- ADDITIONALCOMMENTS ------ ------------------------------ ---------------------------------------- ------------------------------------------------------------------------ 14 ---------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------ ---------- ---------------------------------�W_ , - ----------- ------------------------------------------------------------ ----------------------- ---------------------------------------- ----- Final Inspection by: � �}-- - - Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M