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FOR OFFICE.USE: APPLICATION FOR SANITATION PERMIT Permit No. Z---.�-3-- (Complete in Triplicate) ---------=------- ------------------------------ _-___- Date issued _3._--3= -- L -----"- -----------•--------------- -- -- 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 described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. - ------------- -CENSUS TRACT ---��_ ---------•---.. ------------------------------------ . ---- --------------------- ----- JOB ADDRESS/LOCATION - --------- -------- ------------- Owner's Name. ` ------� _ ------ -------------------------------- Phone City ---- Address - -------�f------------- Contractor's Name ' --------------------------------------------------------------;---- -------- -------- -------- ---- ------------- ------------:----- -- License # ------------------------ Phone ------------------------------ Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Geart ] Motel ❑Other -------------------------------------------- Number ---- -------- -------- ------------------- Number of living units:-.�------" Number of bedrooms __--_-----'.Garbage Grinder ------------ Lot Size ---------"-------- -------------------- --------------------------------------------------------------- ------ ---------•------------- ----•---------------Private ❑ Wa#er Supply: Public System and name --------------------------------------------------------- ---------------- ----•----------•--------- - " Peat❑ Sandy Loam ❑ Clay Loam F]Character of soil to a depth of 3 feet: Sand'[] Silt❑ Clay F1 Hardpan 0 Adobe F-1 Fill Material -------" --- If yes,type ---------------------------- t (Pl'ot plan, showing size of lot, location of system in relation to- wells, buildings, etc. must be placed on reverse side.) V NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) O PACKAGE TREATMENT [ ] SEPTIC TANK�[ ] Size------------------------------------------------ Liquid Depth _._-----------------:•---- Material--------------------- No. Compartments --_-"-_--------- ---- vi Capacity ------- --------- Type -------------------- 1~3 Distance to 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. ------------------•----- De SEEPAGE PIT Depth ---__---- Diameter ---------------- Number --------------- ------------ Rock Filled Yes ❑ No [ ] P ------ Water Table Depth ---------------------------------------- Rock Size -------------------------------- Distance ---------------------- -Distance to nearest: Well -------------------------------------- Foundation ---------------••--- Prop Line ---------------------- REPAIR/ADDITION .-_----------------REPAIR/ADDlT10N(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------11 Septic Tank (Specify Requirements) -------- --------------- --------------------------------------------- -----------.------------- ----- f � 47 --------- --------------------- t Disposal 'Field (Specify Requirements) ----A4_ 4R.- ----- --- --- ----------------------------- -------------------------- ---- ---------- --- ---- -- - ----------------------------------- --- ---- ---- --- -- -- -- - (Draw existing and- required addition on reverse side) I 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. Horne owner or licen- 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 subject to Wo ki's Compensation laws of California." Signed _ -------- -------- Owner ---------- ----------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _- -- ----- •------------- DATE __��'. `- -- ------- --------------- BUILDING PERMIT ISSUED -------------------- - -"----""--- ----=------ ADDITIONAL --------DAT --- --------------------------- ---------- t ---- --------------------------------------------------------------- L COMMENTS -------- ------- ---------- ------------------- -------------- - ------------------ ------------------"-------------------------- ------------------------------------------------------------------------- __ -------- ------- --- ------------------ ---------------------------------------------- ------ - ----- ---- -- --- Final Inspection by: ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT F_ H. 9 1-'68 Rev. 5M