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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - � a Permit No. k.iP----- --------- - /�--- -------- (Complete in Triplicate! - --- ------ ----- � � Date issued ------------ - ------- ---------- ------ ---------=--------------------------- - This Permit Expires 1 Year From 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 County Ordinance No. 549 and existing Rules and Regulations: d -------..CENSUS TRACT -------------------------- JOB ADDRESS/LOC ON ._ �-��--�--��- ---:- ----- --- - Phone Owner's Name -. -- `v -- V\A--.... City - ---------------------------------------------- ----------.License # 1_D�. � - Phone . Contractor's Name ----------- ------- --- ---- Installation will serve: Residence Epartment House❑ Commercial :❑Trailer Court ;❑ Motel ❑ Other --------------------- ------------•------ Number of living units------ Number of bedrooms ---r-_Garbage Grinder ----""--___ Lot Size ----------- -- ®' Water Supply: Public System an name ------------------------------------ ----------------------------------•--------------------- --------------•- Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ Hardpan ❑ Adobe &'/Fil[ 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 seeps a pit permitted if public sewer is available within 200 feet,) f SEPTIC TANK Size__ s -___ Li uid De th --.'`�----------, - PACKAGE TREATMENT [ [ q p Capacity ----�Q. -- Type - - -- - Material--P— NO.. Compartments _ �- r W ,�o -Foundation -----/-Q--/----- Prop. Line --- ---•--------- Distance to near t: Well _.___------ ---------------- ----- -o r LEACHING LINE [41 'D' of Lines -------_--I------------ Length of each line--------- Total Length ----�0---------------- s� ._-_--_De Depth Filter Material ____ "- -------------------•--------- - D' Box AZ--- Type Filter Motel _-_ _- - p � , Distance to nearest: Well ___-��- -----_ Foundation ,�1?-.---------- Property Line __S------------------ cs_-I Diame#er '33``----- Number ------- --------�-- Rock Filled Yes �1 No SEEPAGE PIT [A Depth ____- ----- ��--ff� ----------------------------Rock Size f--'r�10--------- Water Table Depth "--.___--- 1�- r ' Erb r Foundation _-�o-"--.- ----- Prop. Line ----%9_ to nearest: Well __________-_�---- --- ------•---------- REPAIR/ADDITION{Prev. Sanitation Permit# -------- ------------- - -- --- ------------ Date ---- -------------- --------------1 .• Septic Tank (Specify Requirements) ----------------------- ---------------------------------------- - -------------------------- - i Disposal Field (Specify Requirements) ----_- ----------------------------------- --------------------- - ----------- ----- -------------- ------------------------ --- -------------------- ------ -- -------------------------------- ---------- ------------------------------------ (Draw existing and required addition ori reverse side) I hereby certify that I have prepared this application and thatthe}work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules anld 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of,California." Signed -------- ignedOwner v ------------------- Title ------ (If.other than owner) FOR DEPARTMENT USE ONLY zo 6 APPLICATION ACCEPTED BY - -------- -WL� -----. DATE -------- ------------------- ------- -------------DATE -..---------------------------------------- BUILDING PERMIT ISSUED -----------------_----- ------------------------------------------------------- ---- ADDITIONAL COMMENTS -�- --�---- --- -------- ------------ -------------------- ----- --------------------------------------------------------=----------------------- --------------------------- - --- ------------------------------"---------------------- ��'---� -e=->,..�--- ---------- - - ------------------------- Date Final Inspection by: ------------------ ---------- -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M