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i� •, .;OR OFFICE USE: -� • �. 1} APPLICATION FOR SANITATION PERMIT Permit No. -- Z= ------------- k '(IZ,, (Complete in.Triplicate) Z -1L ------------- Date issued ------:-------_-•--- i This Permit Expires-VYear.From bate Issued Application is hereby made to theJoaquin�Local Health District for a permit to construct and install the work herein desc'ibed. This application is made in compliance with County Ordinance No.,549 and existing Rules and Regulations. �F A - [� �-S -� ----- CENSUS TRACT JOB AQDRESS/LOCATION _��-a�- - = � �-------- ------ ----------- ------- I Owner's Name --------§r- Phone l- --- - --. � - - . - License # ---- .-- Address _ - - -------------'--• Contractor's Name ____ �- ---- ---- , T Installation will serve: Phone Residence ❑ Apartment House❑ Commercial ❑ raile C ourt ',,F] _ L �p Motel ❑ Other ----------------- ------------------------- E Number of living units:------/--- Number 'o droon�� -=-_Ga"rbage Grinder�J�-.-- Lot Size __ __-�___�-�-------------------- Water Supply: Public System and name __ / Private ❑ Character of soil to a depth of 3 feet: i Sand'❑ Silt❑"' Clay 2] Peat❑ Sandy Loam-❑ Clay Loam ❑ Hardpan ❑ Adobe, - ill Material _ _____a-- if yes,,type (Piot..plan,_showing.size.of..lot,.,location,of,system in relation 22 wells,-buildings, etc. must be placedonreverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ I SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth -------------------------- Capacity - --------------- Type '[-------'---------- Material---------------------- No. Compartments ------ --------- •-•-- Distance to nearest: Well ---------------------------------Foundation ---------------------- Prop. Line ------•----------- LEACHING LINE [ I No. of Lines ------------------------- Length of each line-'-_-_______--------- ---- otal Length—__::`--__-_-___.-------.-.-- 'D' Box7ype Filter Material __ ;---'--=DepthFilter Material --------------------i_--_______-----------•- Distan a to nearest: Well ----------------- Foundation - Property Line !--------------------- SEEPAGE _-_ __.SEEPAGE PIT [ ] Depth ------------------------ ____--- -- Diameter '--------------- Number -------------------- "--'__ Rock Filled Yes ❑ No ,0 Water Table Depth ----- --------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------.----•------•- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ______________-------------------1 Septic Tank (Specify Requirements) === --- ----- -- -•----------------------------- ---- ---------------------- 1 Disposal Field (Specify Requirements} =.Y__.___ -----•, =- - � ---------------------------- ------------------------------------------------- -- ----- - ----------------------------------------------------------------------------------------------------:--------- --------------------------------------- - - [Draw 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 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 owner) E ARTMENT USE ONLY w. . --------------- APPLICATION ACCEPTED ,BY - ----- - --- ------ --------------------------------------------------- BUILDING =--------------------------- ----- DATE __.. = y BUILDING PERMIT ISSUED ----- DATE -------------------------------- ---------- ADDITIONAL COMMENTS ----- --_ _ _ ------------------------'`- --------------------------------------------------- ------------------------------------------ -------------------------------------------------------------------------------- --------------- -----------------------_------- Final Inspection by: ------ - - ------ ---------------------------------------------------Date ----fir - � =------------------- SAN -------------- SA �dDAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ✓✓