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FUR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ----------------------------- --------------------------- \ --------------------------- ----------------------------- ; This Permit 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 Coynty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATC' _ _ ____ _' _.�` --------------------------------CENSUS TRACT ._�-�7___-________ Owner's Name -----(,!"} ------ _=c_f � hone Address -- ---- --- --- -- it � ----- ------------------ ----•------ Contractor's Name -- ---- �.W �--License # _1Y1�yPhone ------- ---------------------- Installation will serve: Residenment 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 ❑ 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) // PACKAGE TREATMENT [ ] SEPTIC TANK: Size_-____�__��_ �'-__�_ _______ Liquid Depth _-I_____ .. %Capacity JC'P._1', _ _ Type p --- Material__ -d�`- - No. Compartments ___ ......_ u � �� Distance to nearest: Well ---------. _�_______________Foundation ------/0--/----- Prop. Line __ LEACHING LINE [I') No. of Lines -----]------------------ Length of each line.____1__Q.!--------------- Total Length ____--_p_a_--__________. �i - 'D' Boxes_.. Type Filter Material -----s_'-1-2_____Depth Filter Material' ____ ___________ Distance to nearest: Well ____:��'_l______ Foundation -----/0--�_______ Property Line -- ----_------------ SEEPAGE PIT Depth ---�2-------- Diameter -- _______ Number ---------- Rock Filled Yes No C� � 1 I / rr i. Water Table Depth -----------------� --------------------Rock Size x i Distance to nearest: Well _____________1b!`--___—_________---Foundation _----/_.(?......... Prop. Line ------ .......... REPAIR/ADDITION(Prev. Sanitation Permit r# -------- ----------------------------------- Date ----------------.-.•--------------) 4 SepticTank (Specify Requirements) ------------------- ----------------------------------------------------------- ----------'-'----------------------------------------------- DisposalField (Specify Requirements) ---------------------------•--------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 manner as to become subject to Workma" ompensation laws of California." Signed - - ------------------------ Owner BY ------ ---------------------------- � Title --- ------------------------------------------------------------ (If other than ow er) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _-/'___ -_ �___________------------------------------------------------------ DATE _ ''o _5�� ---------------- BUILDINGPERMIT ISSUED -----------------------------------------------------------------•------------------------- -------DATE ---- -------- ---------------------------- ADDITIONALCOMMENTS ------------------------------------------------------------------------------- --------------------------------------------------=--------------------------- ------ ---- - - ------- ----- ----------- _ t _ R __. = ----- ----- --- Final Inspection by: -----------------------------------------------------------------------Date 1'��-7�------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 0 E. H. 9 1-'68 Rev. 5M