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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------- -------- Permit No. _ _- /��` (Complete in Triplicate) ------------------ -- - ----------------------- Date Issued ___:J_��'�� -------------------- ------------------------------------ This Permit Expires 1 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: 7 JOB ADDRESS/LOCATIO CENSUS TRACT Owner's Name -�' -------- --- - -------------(/--------------------------------- ------- -------------Phone -------------------------------•---- Address ---------- � ---- ----- ---- ----- City a c Contractor's Name --------'- --- --- - --G -License # -1"Mf --- Phone ------------------------------ Installation will serve: Resident [Apartment House_❑ Commercial []Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number of living units:-----t----- Number of bedrooms Z-------Garbage Grinder _- ________ Lot Size ________-______ ----- Water Supply: Public System and name --------------------------------------------------------------------------=------------------------- -------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam .e Clay Loam ❑ Hardpan ❑ Adobe ❑ 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,) PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size__________________________________________ Liquid Depth -______________-__ ...... Capacity -------- ----------- Type -------------------- Material--------------------- No. Compartments -•---- -•----•--•-•-•• Distance to nearest: Well ______________________________Foundation ---------------------- Prop. Line -----------__------ LEACHING LINE 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 -----------------.---___ SEEPAGE PIT [ j Depth __________________ Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size ------------------------------ Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ------ ............... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ------------------- ------------------------------------------------- Disposal Field (Specify Requirements) ------------------ ----------------- -------------- ----------- --------------- -------- ---- --- �.a 1 ----------------------------- ------1_4 tm- � ! _0_,* x �� - -�- c - t 1-- - ----------------------------- 0 (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 sub' Workman's Compensation laws of California." Signed --------- - --- - ----------------------- ---------- C% ------ --- - -- Owner Title ----- ----- -� -- ----------------------------- BY ------------------ - ` - (If other than owner) v FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY __ __ __ _ _ zit t i ------------------------------------------------------------- DATE __ '.rz" ." ______________ BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------------------ --------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ -- ---- --------------------- ----- _ -----.----------------------------------- ------------------------------------------------------ VV "y Final Inspection by: z� ------------------------------------------------------------------- ---- ate SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M