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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- (Complete in Triplicate) --------------------------- This Permit Expires l Year From Date issued Date lssued.._Jr.__�.�_�_.:? ---------------------------------------- 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 compliancewithCounty Ordinance No. 549 and existing Rules and Regulations: N ` aft ----._CENSUS TRACT JOB ADDRESS/LOC Owner's Name -- -- -------- - Phone-----------------------------------------------------------------------.Q� -------- City --- Address ------f__ �� ._ - - - ---- ---- / Contractor's Name ------ - ------ - -------- ,--f-- PJ-License # ----------------y- Phone ------- Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court J Motel ❑ Other - --------------------------------- ------- Number of living units:.....i_----- 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 ❑ Hardpan Adobe ❑ Filt Material ________ if yes,type --------------------- ------ (Plot plari, 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,) Liquid Depthth ------------------------ PACKAGE TREATMENT SEPTIC TANK[ ] Size Ca acitY ---- ----------- - Type -------------------- Material---------------------- No. Compartments --------- Distance •- v to nearest: Well --------------- _ - _ ___________- __ -_Foundation ____._--------------- Prop. Line --___-_--------•-•--- � • LEACHING LINE [ ] No. of Lines ------------------------ Length of each line----_____-----------.------ Total Length ______----- ..------------ Icill 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ---------------------------------------- �J ------ Foundation __ Property Line ------ •------- Distance to nearest: Well _______________ ---------------------- SEEPAGE PIT [ ] Depth - Diameter ______ _________ Number ---------------------------- Rock Filled Yes [] No 0] WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------- ------- REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------- -------------- Date ----------------------------------) ------------- Septic Tank (Specify Requirements) ----------------------------------------------------- --------------------------------------------------- — Disposal Field (Specify Require nts) ---- - --'----'--------------- -- ----- f� 5�-` '' 1---- --- - - ---------- -- ---- ----` -- .X ------------------------------------ - ------------------------------------------------------------------------- ------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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 become subject to Workma mpensation laws of California." Signed -------- ----------------- Owner ------- ---- fi LTitle --- ------------- ------------------ (lf other than wner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- -- -- -----------------•- ---------------------------------------------- DATE __ _'_.t -__3_'7_ -•--------- BUILDING PERMIT ISSUED --------------------------- ---------------------------_-DATE ------------ ADDITIONAL COMMENTS ------------------- -------------------- ----------------------------- -------------------------------------------------------------------- -- ------ - -- ------------- Final Inspection by: __ _ - .______.Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M