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FOR: OFPiCE USE: APPLICATION FOR SANITATION PERMIT Permit No. ----------- --IF----------------------------- (Complete in Triplicate) ---------------- ------- Date issued f This Permit Expires I 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.. J -s.�..- -��.----- �� -`- ��-` -�� ------� - �:- --,- -..CENSUS TRACT -------------------------- OS ADDRESS/LOCATION Phone --------------------------------- --- ------ Owner's Name ----/ Address ----- ----------- City ------ Contractor's Name -. _- .License # Installation will serve: Residence FJ Apartment House'F1 Commercial Trailer Court Motel ❑Other --------------------------------- ---------- • a� ---------------- Number of living units!. - Number of bedrooms -...-..Garbage Grinder Lot Size _----------- -------- Water Supply: Public System and name -------------------------- -------m_i------------------------ ----Private ❑ Character of soil to a depth of 3 feet: Sand'❑ _ Silt.❑ Cla ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe 96 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.) V NEN INSTALLATION: (No septic tank or seepage pit permitted if public,,,sewer is available within 200 feet,) O PACKAGE TREATMENT [ ] SEPTIC TANK f-.] - Size---------------- ---- Liquid Depth ----------=----- V Capacity -------------------- Material ±------------ No. Compartments -----------------•- --------- -------- TYpe f Distance. to nearest: Well ------------------------------------Fou id6tion ---------------------- Prop. Line ------------------- " No. of Lin*es�------------------------ Length of each line-- ----- '---------- Total Length ----------------•----- ---- LEACHING LINE [ ] i 1. 'D' Box ------------ Type Filter Material ---------------------Depth Filter Material ----------------------------------- ---- ? . Foundation -�-------------- Property Line --------_--------------- Distance to nearest: Wel[ ....................... - .. Number ..-_'_.._- Rock Filled Yes No ❑ f SEEPAGE PITT Depth --__- -------- Diameter .. :-.---- ---- .� Rock Size =-------------- --------------- Water Table-Depth --- -- --- , Distance to nearest: Well -------- - -------•------------Foundation -----f77 Prop. Line .------- ---•----- REPAIR DDITIO Prev. Sanitation Permit# ------------ Date -_____r,l----------- ;---------) Septic To (Specify Requireme "-�"---6--="=. - *�f` - ' - - Disposal Field {Specify Requirements) ------------- ---_kY------- ------ -------------------------------------------------- --- ----------------- -------------------------- A .. ........................--..!------....----.___..._ _-....-_....._- ----..._..----------------------- ---------------__.._----...._...._------- .-....._ - ----- ._ ..._._._._ s Y ----------------- ------- ------- --------------------------------------------------------------- j (Draw existing and required addition on reverse side I hereby certify that I have prepared this application pnd that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Locals 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 ------- --------------------- Owner �_ f�� --------------- Title (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- --- - - ---------- -------------------------------------- DATE ��-� S'`�a- - - ---------------------------- BUILDING PERMIT .ISSUED ------ -- --------------------- DATE ADDITIONAL COMMENTS ------------------------- ------------ ------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- ------ -- - - -- - ------- - - -------------------------------- --- -- - Date----------------------------------------------------------------------------------------------------------------- --- -- Final Inspection by: -- ------- I- .- - -- ---------- 5AN JOAQUIN LOCAL HEALTH DSTRICT C E. H. 9 1-'68 Rev. 5M