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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. _Y.- (Complete in Triplicate) - -- -----------•------- Date issued ,- - - This Permit Expires 1 Year From Date Issued . Application is hereby made to the Son Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: XJOB ADDRESS/LOCATI -_ :----CENSUS TRACT ------------------- one ------------------------------------ Owner's Name _ ---�'� - r�-�as��4� - - - �--•- - ------- - ---- --• City -�---------��C�--------------------•------- --- Address -_------ c � :License # e- Phone Contractor's Name ________ `1vf�1-��--- - --- Installation will serve: Residence partment House,❑ Commercial ❑Trailer Court 0 Motel ❑ Other ------------ ---------------------------- Number of living units:_____f_--- Number of bedrooms <___>_:___Garbcge Grinder ------------ Lot Size _________________________________-- Water Supply: Public System and name ------------------- `--------------- Private ❑ d Cl ;❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay El Peat❑ Sandy Loam ay Loam Hardpan ❑ Adobe❑ Fill Material__-______-__ If yes, type ____________________________ I {Plot plan, showing size of lot, location of system in relation t o 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,[ ] ,IN. Size------------------------- ---------------------- Liquid Depth ----------------- Capacity ------- Type -=------------------ Material---------------------- No. Compartments -------------` p tY -------- -- YP I Distance—t& nearest'-Well ------------.Foundation------------------------:- Prop. Line ------------- ......... LEACHING LINE •[ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length .------•----_-------'-------- * - 'D' Box ---- ------.Type.Filter,Material .---- ------------- ,Depth .Filter Material ,---------------------•------•------- -------- - Distance to nearest: Well ------------------------ Foundation --------------=--------- Property Line. ----------.-.---- SEEPAGE PIT [ ] ' . Depth < ------------------ Diameter ---------------- Number ------------------------- -- Rock Filled Yes E] No f3 s. Water Table Depth -Rock Size -------------------------------- --------------------------- iDistance to nearest: Well ----------------------------------------Foundation ----------- -------- Prop. Line --------------'-------- y f REPAIR/ADDITION Wrev.;Sanitation Permit# -------------------------------------------- Date --------------------------.------ s ' Septic Tank (Specify Requirements) ---------------- ----------------------------------------------------------------------=--- -------------- w G � � I Disposal Meld (Specify Requirements) ____ r�� ,tea___ _______ _____r------- ------------------ -------- 8 (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 Iicen- sed agents signature certifies the following: "1 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 su t to Workman's Compensation laws of California." s Signed - ------- = -- ----------- Owner BY -------- -- ------ Title ---- --- ----------------------------- (If other than owner) ` FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B ___ ---------- ------- Z—fid e DATE BUILDING PERMIT ISSUED --------------------- DATE -------------------------------------------------------------------- ADDITIONAL COMMENTS --------------------------- -------------•---------------- -------------- -------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------- -- ---- 1- -------------------------------- - - -- --- - - =---------- -- - = ------ 4 Final Inspection by _ Date ---- _' -_�--------- "�- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.