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FOR-OFFICE USE: APPLICATION FOR SANITATION PERMIT v -------------------------------------------- Permit No. ---- -.-a_ - (Complete in Triplicate) --- --------------------------- ----------------_---.-----.-----_--_--_- --------------- This Permit Expires 1 Year From Date Issued Date Issued __ �.�s. 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: fr/ JOB ADDRESS/LOCATION .. _ _ � -----�t----- CENSUS TRAgC�T � Owner's Name / �-!�/ --------- r_ :1��- _----- - ----Phone .A;C :!3- ----- Address � ------ _ ------- ------------------- City l t� r / ---------------------- ------------ Contractor s Name ------_ -- A .-----CZV-/e--------------------License # 't-- ----- Phone -----` -_- Installation will serve: Residence ❑ Apartment House❑ Commercial❑Trailer Court ;❑ Motel ❑Other -- ------------------------------------------ Number of living units:------ Number of bedrooms ______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 -❑ 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 { a SEPTIC TANK'[ .] . Size---------------------------------- ----------- Liquid Depth ______________________ Capacity --------------------- Type -------------------- M erial----------- --- ------ No. Compartments ------ ----------= Distance to nearest: Well _______________________ ___________F,ou ation ____________________ Prop. Line _--.____________._-_._ LEACHING LINE [ ] No. of Lines _____._ g _.__.___ Total Length _______________ J D' Sox _ Type Filter Material e _ Lent o enc line Yp --- - ---= ` pth Filter Material -------------------•------------------------ Distance to nearest: Well ____________ ___________ Foundation -_--._________._________ Property Line. .____--._--_.__.__._.___� SEEPAGE PIT ['] Depth ---_ __-_ Diametery______________ Ndrriber ----------------------- Rock Filled Yes ❑ No ❑ Water Table Depth ----------- --------------------- = -------Rock Size ------- -------------------- Distance to nearest: Well ------------------------ _-------._Foundation --------------------- Prop. Line _---------.-- ........ 0 REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------------------'---- Date ----------------------------------) SepticTank (Specify Requirements) ----------------------------------------------------------------------------------------------------------- -----------------------••----- Disposal F' I { ecify Requirements] - •-----------=----------------- -- ---------- Z IN- ---- - -- --- ----------- ------------ - aJ ma ----- - _-Cf --- ------- -. y -z-� -------- --- -- --- - - - ---- - ---- ------ ------4SX------ (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 Mules 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 becT zz;;7 alifornia." Signed __ __ Owner BY -------- -------- -Title ----- --- - ---- ------------------------------------------------------ raoe O EPARTMENT USE ONLY APPLICATION ACCEPTED BY --------- ------------- ------- DATE ------- �_ !-�-_ �----- ----- BUILDING PERMIT ISSUED ------------- ---------- ------------- -------------------------------------------------------------------DATE -- ---------------------------------------. ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------ - ---------------------------=--------------------------- -------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------••-.----- ------------------------------------------------------------------- -------------------------------------------------------- ----------------------------------------------------------------------------- --- ------- Final Inspection by: ---- ---------- --------------------•---------- ----------Date ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M