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FOR OFf=fCE USE: - cAPPLICATION FOR SANITATION PERMIT _��. r-% --------- --- Permit No. - _,7 (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 ount Ordinance No. 549 aW-ti fisting Rules and Regulations.. 014 JOB ADDRESS/LOCATION ._ — ---------- ------------- ----------- CENSUS TRACT .. Owner's Name ' - Phone i------ ---- ------------ -- CityAddress • -----!Contractor's Name --- Installation will serve: Residence beApartment House❑ Commercial (-]Trailer Court ,❑ Motel ❑Other ------------------------------------------ Number of living units:..- ___ Number of bedrooms ---tom----Garbage Grinder --- Lot Size __ _ --------- Water Supply: Public System and name ------------------------------------------------------------------------------------- -------------------------Private Rr x Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan' Adobe.[] 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.) ,� a NEW INSTALLATION:— -(No septic tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT f ] SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depth -------_------------ Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---------------_- v Distance to nearest: Well ------------------------------------Foundation --------------- '+Prop. Line,------"-------- LEACHING LINE [ J No. of Lines -------------{---------- Length of each line---------------------_----- Total Length ---------------......_.._-_ . y 'D' Box ------------ Type Filter Material -----------------i-Depth Filter Material --------_-----------.---------....--.--••---• Distance to,nearest:'Well _---------------k------- Foundation -----------------------03rbperty Line --_---- ----------------- SEEPAGE PIT [ ] Depth ------_1---------- Diameter -------I-------- Numb+er ----------------------- _- Rock Filled Yes ❑ No 0 . Water Table Depth ------------------------------------------_- _Rock Size - ----------------- f �----- # r i -1: Distance to nearest: Well -`-_------------------------------------Foundation s---------- ` ---- Prop fi Line ..........____.-_----- REPAIR/ADDiTION(Prev.?Sanitation Permit# _.-----_---------------=EE-------------------,Date r------._^---------------_--------) Septic Tank (Specify Requirements) -------�� -------4�'_�_ �- -� --- -------------------------- - -=-� - ---�- *teF._� 4-~b. Disposal Field (Specify Requiremen#s) '� , t -------------- ---------------�------- ------------------- ------------------ -- ---- r . ° ' .. - ---------- -------- ------------------------------------------ ---e.'rsting and required addition on rev rse side) ve I hereby certify that i have prepared this application and thatithe' 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 liven sed agents-signature certifies the following: sa! "I certify that in the performance f the work for which this permit is''issued, I shall not employ any person in such manner as to bewme,s bject to rkm tlon Compensalaws of California.":t Signed -- ------ Owner BY ----------------------- - --`-------- -- ' Title -'------------------------- -------------------------------------------- (If other than owner) ` r . . FOR DEPARTMENT USE ONLY f/ APPLICATION ACCEPTED BY -------'-------------- DATE ��-7 -�' BUILDING PERMIT ISSUED ------------------------------ ---------------I-------------- ----------------E--------------DATE -------------•-------•--------------------- ADDITIONALCOMMENTS ---------------------------------------------------------f--•-------------' ------------------------------------=-------- ------ -------- ------------------------------�--------- ------;�------------- __: F - ----------- ------------------------- ------------------- ------------------------ --------------------------------------------------------------- -------- ---------- -----------' FinalInspection by: --/- - -----------------------------------------------------------'--Date --- ---- ----- ------•-------'--- ------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.