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I FOR OFFICE USE: Cod) APPLICATION FOR SNITATION PERMIT -----� (Complete in Triplicate) Permit No. ---------------- ThisPermit Expires 1 Year From Date Issued Data Issued - d 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 County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATI N ..-.._. ' �� ------------------ ----------------- - ------------------ ----CENSUS TRACT Owner's Name ------ L)ir !'� - ------ , �^ G ------------Phone Address -- ---- ----- - ------- -------------. city --=�� --�- ---------------- Contractor's Name - ------- - --------------- -----------License #/IS Phone Installation will serve: Residence ZApartment House❑ Commercial❑Trailer Court ;❑ Motel ❑ Other - ------------------------------------------ Number ----------------------------- ---- - Number of living units:__---/-.--_ Number of?�drooms i .-_Garbage Grinder -----�--- Lot Size ��_,��-��___- - •- Water Supply: PublicSystem and name - �_�t ___-- , ? '---------------------- ---------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt.❑ Clay ❑ peat❑ Sandy Loam ,❑ Clay Loam ❑ Hardpan ❑ Adobe X Fill Material _e - If yes, type ---------------------------- (Plot ------------------- --(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:[ l Size-------------•-----_---------------------------- Liquid Depth . - --------- Type --------------Capacity ---- Material---------------------- Na. Compartments ---------•-------=---- Distance ,i to nearest: Well ----------- ---_.Foundation ---------------------- Prop. Line ------------•--__-- �7 LEACHING LINE [ j No. of Lines ------------------------ Length of each line---------------------------- Total Length -.___------ `D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------- Distance -- - _ .Distance to nearest: Well ---------------------- - Foundation _.---------------------- Property Line a SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No Water Table Depth ------------------------------------ ------.,.--Rock Size Distance to nearest: Well --- -----------------------------------Foundation --------------- ---- Prop. Line --------------- REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date ----------------------- Septic _----------- .___-_-_Septic Tank (Specify Requirements) ----------------------------- ", - ------------- =------------------------------- Disposal Field (Specify Requirements) ----- --••--;_. �-r_ �i �_-_---- t�a ------------------------------------------------------------ ----------------------------------------------------- --------------------------------- ----------------------------- ----------------------- raw 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 l 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 Workman's Compensation laws of California." Signed ----------------- Owner BY ------------------- --------- ------------------------ ------------- ---- - ---------- - -------- Title (If other than owne ---------------------------- FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. _ BUILDING PERMIT ISSUED -_-__ -----_._ - ------------------------------ - -------------------- -------------- DATE ----tu_ —h ----------------- ) ADDITIONAL COMMENTS fsr. rwe �,T----------------------------- ----------------------------- _---__ .-- ------------ -- -------- ----------- f� - - --------------------- ----- - -------------- -------- ----------------------- - --------- - ----- --------------------- - Date -- --" - ----------------------- - - - --- - ------------------- --- -- -- -- - ---- ------- -------- ------------- ----- - _- --- - Final Inspection by; -------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M