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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ N --------------------- - - 4 3� =_1R Permit o. (Complete in Triplicate) ;i. = -SFr" i ..a S— �_ Date Issued --_------ -------- J This Permit Expires 1 Year From Date Issued _ Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein 1 described. This application 'is made in compliance with County Ordinance No. 549 and existing Rules and Regulations.,,- ..r a� CENSUS TRACT = JOB ADDRESS/LOCATION - d'3-----.--- ----- ------ Owner's Name -- ----------------------------------- C ---- -•---------------- Phone Address - - 3 =- - -------------------------- City -< .. --- ---- -- ------- ' �' "�-License# �f� 3 ' Phone Contractor's Name �` Installation will serve: Residence 03,Apartment House❑ Commercial ;❑Trailer Court iio r Motel ❑ Other ------------------------------------- ------ Number of living units------------- Number of bedrooms ----)------Garbage Grinder ---------- Lot Size - _s. -_ ------ --------- -,-- Water Supply: Public System and name -------------------- --- -----.-------------`------------------- ---•------- -Private Character of soil to a depth,of 3 feet: Sand'❑ Silt❑ _ ..Clay.,❑v. . Peat❑i, Sandy Loam .I] Clay Loam:❑ , i 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,) j PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size-----"-----•----------- Liquid Depth -------------------i No. Compartments _-. -^.-. ------. Ci Capacity --�-�B-Y------- Type ----=-- -------"---- MaterialL -�' # Distance to nearest. Well ------------------------- ----------Foundation -------------.Prop. Line -------------- Y------- V el LEACHING LINE [ ] No. of Lines ----- ------------ Length of each line----- ----------------- Total Length ,_ p_-.._---_.._ ---___ 'D' Box -_- ------- Type Filter Material - -----Depth Filter,Material --- ---------- �\ Line. ------- ...... Distance to nearest: Well ------------------------ Foundation � ------ Property SEEPAGE PIT [ ] Depth -------------------- Diameter --------------- Number ---_-----------___------ -- Rock Filled Yes [] No 0 Water Table Depth -----------•, ==- _..Rock-Size -------------------------------- 4 - Distance to nearest. Well --------------------- ----Foundation -------------------- Prop. Line ._---_-_-.___.-._-.. REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---•---------'---------•----------1 4 -------------------------------------------------------- Septic ` - Septic Tank (Specify Requirements) -------- - --------- ------ - : ------------ Disposal Field (Specify Requirements) -----------------------------•--------•------------------- -------------------------------------------- ----------------------------------------------------- 'f _ -------------------------------------- (Draw - --- ------- -- -" - - __-_--_----_ ----------_-----------_-----------._--_-__--_-----_---------------_-_-_------------_--_-F_-_-_- .. - (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. f ' as to become subject to Workman's Compensation laws of California." Signed ------------------- Owner - ------------------- ------ ---------------- _ Title ------------------------------------------ BY ---------------------------- (if other than owner) FOR DEPA MEN USE ONLY APPLICATION ACCEPTED B DATE ---= -------- -------•-------- G -- ----------------------------------- _._ _ DATE ---- BUILDING PERMIT ISSUED ------- -- ADDITIONAL COMMENTS 'G ha �c _ - - --------------- ---- -------------------------- i ---------------------------------------------------------------------------------------------------------------- ---------------------------------- ------------------------------------------- - --- - - ------- �. Inspection b � -------- Date --- ------------------------- Final • P Y: ------ r - - - - ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT _ E. H. 9 1-'68 Rev. 5M