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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No: ----------------------------------------- ---------------- This Permit Expires 1 Year From Date Issued Date Issued ___r _ 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: t JOB ADDRESS/LOCATI ._ ;"-"__�'Cf_"" ----- -:----CENSUS TRACT Owner's Name --------------------------------------Phone r. Address _ Cit -- s -------------------------- = Contractor's Name -.____- ------- --s.�. -___ _ -- License Y Phone Installation will serve. Residence partment House❑ Commercial:❑Trailer Court ❑ Motel ❑ Other Number of living units:-------I___ Number of bedrooms -._ ---- Grinder ._._.______ Lot Size ____ - -------- ------------------------- Water Supply: Public System and name .................................... __________ __ ___ _ __- / " - - - _ Private [L�� Character of soil to a depth of 3 feet: Sand'❑ Silt --'Clay❑ --' y ❑ Peat❑ Sandy,Loam ❑ Clay Loam ;❑ Hardpan �/_Adobe❑ Fill'Material ......-----If yes, type ---------------------------- (Plot plan, showing size of lot, location of system in.-re tion to wells,'buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage p.it permitted rif p blit sewer is available within 200 feet,) PACKAGE TREATMENT [ ] 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---------------------------- Total Length --_--------_ - T` D' Box ___-.` N Type Filter Material __________________Depth Filter Material ----------- Distance to nearest: Well -------- %I. ------- Foundation -------- ------------ - Property Line ---- SEEPAGE PIT [ ] Depth Diameter -------£-- '_- Number --------------------------- Rock Filled Yes ❑ No i❑. y Water Table Depth ----------------------------- -------`Rock Size `' Distance to nearest: Well ----------------------- ----- -`- -----Foundation --- ------ Prop. Line "------•-------------- REPAIR/ADDITION(Prev. Sanitation Permit e# _._:___.._ �____-__________ - r ► -------- � Date ----------- --------- Septic Tank (Specify Requirements) ----:--- _----------------------------------------------- Disposal Field (Specify Requirements) ---_-- ` _ ---------------•- ---" f_t �3 w � -- ____ f/ ------------------ -- ---- ------ (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 F 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, 1 shall not employany person in such manner as to beco._ ubjecWorkman's Compensation laws of California." ' 1 Signed _ _ ------ Owner BY ----------- (If Ti#le (If other than owner) -- --------------------------------- t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - --------------------------------- ---- DATE - -��3�� BUILDING PERMIT ISSUED ---------- -------•------------------- ------DATE - ------------------------------- ADDITIONAL COMMENTS -- -----------� - -------- - ---------- ----------------------- ------------------------------------------------------------------ ------------------------------------------------ ------------------------------------------ -------------I-------------------- `------------ ------------ ---------------------------------------------------- ----------- ---- - Final ins action b �, _ � --.- -""_.-_____ P Y F l �� --------- ---------------------------------- -----------------------------------------Date -------- ---- ---�t- - �• SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M