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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No, ------------------- -- (Complete in Triplicate) --------=----------------- --------- Date Issued _-""-------- - ---• , This Permit Expires 1 Year From Date Issue - Pp --------------- 1 rein Application is hereby made to the San Joaquin lion ec withal County alth tordinance rict for a permit and existing Rules tand Regulations- described. egulat l the workons- described. This application is made in p /` _ n _ CENSUS TRACT�y --- JOB ADDRESS/LOCATION l -d-- : y �Z 'v Phone _ d n- -A" ' -------- � n- /v r��5 Owners Name �� « c -_ -- ss = ------------- - Addre � License # ------------ --- -- - Phone Contractor's Name Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ;❑ ¢ O %1 -h_�� Motel [71 other ----�- ----- -- ----------- € � Garbo e Grinder -------"---- Lot Size -- --------- -- - ---------- Number of living units:_---_�___- Number of bedrooms ._____-____ g Private ---------- - -------------------- ----------- ------------------------------------- Water Supply: Public System and name ------------------ -- - Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ !k Hardpan E] Adobe E] 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,) L c' '� ------------ - ---------- O- Liquid Depth PACKAGE TREATMENT [ ] SEPTIC TANK;[ ] CLQ No. Com artments ------- Capacity /�o TYpe1 --------- Materidi_ ''' . poC� Foundation __- -------- - Prop. Line ------------------- - Distance to nearest: Well ---_-___--_�0- - _ D------- ------- Total Length ,�.(�------------------- TTt No. of Lines ----3- ------------ Length of each line_ _---- - LEACHING LINE [ 1 " l�-�C�C— Depth Filter Material -/ --------------------` -- --- i 'p' Box ----�"---- Type Filter Material -------------------- p � Foundation --- - -------------- Property Line �.__.--------------- Distance: to nearest: Well ----i ---- - Depth Diameter ---------------- Number -.------------- Rock Filled Yes ❑ No ❑ rb SEEPAGE PIT [ ] p ___-_s ` - ----------•---•----Rock Size ---------------------------- Distance - ---------------- ---- --- -- Water Table Depth --- ------- --------------- - - Distance to nearest: Well ----------------------------------------Foundation ------ Prop. Line -------•--------- I " REPAIR/ADDITION(Prev. Sanitati I on Permit# --------------- -- I Septic Tank (Specify Requirements. _""------------ ---- -------- - -------------- ---------------------- Disposal Field (Specify Requirements) _______________________ -------------------------------------------- --------------------------------------- ------ ------------------------------------------ -------------------------------------- 11---- ---------- ------- -- --=--------- ----- ------------------------------------------- =' ----- I - {Draw existing and required addition on reverse si e 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 as to become subject to Workman's Compensation laws of California." -------------- - ---- Owner Signed --. -- ---- - -- - -- ------ -------�--- -- --------- ---- --------- -------- - Title --- ---------------------------------------------------------------- BY -- --- - (If other an owner FOR DEPARTMENT USE ONLY - DATE .__ ----------- APPLICATION ACCEPTED BY -- -------DATE ------ --------------- - -__-- - ----- - ------- ------- ------ -------------- •---- BUILDING PERMIT ISSUED ._----5----------- ----------------------------- ---- --------- ----- ADDITIONAL COMMENTS ---------- ------- ---- -F-ina---l Inspection b-- ---------------- .,, ------ ---- ------ ------------------Date ------------- - - ------- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M