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FCrR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------- ., Permit No: -� (Complete in Triplicate) -------------------------------- w _ 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/LOrrCA��TION p r --------------------CENSUS TRACT -------------- ---�-�------- y Owner's Name NamW. Phone ? --�� Address ------ --------------- --------------------------------------------- City ------------------------------------------------`- �TLicense # l ---- PhoneContractor's l Installation will serve: Residencej'Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number of living units:_____!_____ Number of bedrooms -------Garbage Grinder -------- Lot Size -----•---. , Water Supply: Public System and name'- ----- a-------------------- ----.-Private ❑ Character of soil to a depth of 3 feet: Sand' ] Silt Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe$_Fill Material __________ If yes, type ____________________________ y (Plot plan, showing size of lot, location of system in relation to wells, ,buildings:—.etc:+must be placed on reverse side.) or NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 204 feet,) t PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------- ------ Liquid Depth -------------------------- W Capacity -------------------- Type -------------------- Material---------------------- No. Compartments --------------- , Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------- ..---- LEACHING LINE [ ] No. of Lines ________________________ Length of each line --------------------------- Total Length _---__._______-_________--_ 'D' Box ____.__-- - Type"Filter Material ___________________Depth Filter Material _____.______ 4 Distance to nearest: Well _______________________ Foundation _-___`----------------- Property Line- _________________._-.- ; SEEPAGE PIT [ ] Depth ___________________ Diameter _____-__-- _________ Rock Filled Yes No --- Number - - -------- ❑ ; WaterTable Depth -------------------------------------------------Rock Size -------------------------------- a Distance to nearest: Well -----_----------------------------------Foundation --------------- ---- Prop. Line __________..________-_ 41 REPAIR/ADDITION(Prev. Sanitation Permit# ----- "---'""'-�----------------- Date ____________________--------------1 } .° Septic Tank (Specify Requirements) -- 4F" ------------------------------------------------------.------------------ ------ i - Disposal Field (Specify Requirements) -------------------------�-=� / ------&;=mss ------. ... -------------------------------------------------------- _ _ ------------------------------------_____ -'__"------------------`-----------r-------------------------------------------------- ------ _ -------------------_ _ ___ ___ - _ /� �S__I ___'► t .(Draw existing and required addition on reverse side) j 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 manner as to beco dBiect to W rkman' .Com nsation I ofalifornia." t Signe , c�� Mj__�- =---------owAer_. BY -------------------------------- /��'"�-� - - ----- ------- Title ------------------- -------- -------------------- ------------------- (If other than owner) gn FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------- -------------------------------------------- DATES BUILDING PERMIT ISSUED ------------------------------- ----------------------- ------------ ---- - ----------- -----------.----DATE -------- ---------------------------------- ADDITIONAL COMMENTS -------- --------- y-zs.. __________________________________ -----_______---- __:_------------------ ------------------------------------------------------------------------------------------------------ ------------------------------ Final Inspection by. � ------- Date ?G` --------------- -------- SAN JOAQUIN LOCAL HEALTH DISTRICT I -E. H. 9 1-'68 Rev. 5M