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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Pa t-cz� (Complete in Triplicate) Permit No.------------- ----------------------•---------_-____ This Permit Expires ] Year From Date Issued Date Issued _/ �I Application is hereby made to the San Joacfuin Local Health District for a permi0to construct and ihstall the work herein described. This application is made in compliance with County Ordinance No. 54� and existing Rules and Regulations: JOB ADDRESS/LOCATION .,°:/-- - "7.7 l � _ ---CENSUS TRACT Owner's Name ----- �>' -=---=---------------------------- Address ---- � --Phone - ------------ ---------------r---------------------------. City " - - • ----••-----------•- Contractor's Name -__--. _ � - - -------------License � ' _-- Phone �ZJ6 "� l Installation will serve: Residence Apartment House Commercial ❑Trailer Caurtl �f i❑ Motel ❑ Other -------------------------------------- ' F Number of living units:____--_-__ Number of bedrooms ___.Garbage Grinder _ -*Lot� Lot Sjze` v� --------------------- - Water Supply: Public System and name .._______----__-____- _- -----•----- ------Private]` ---------------- ------------------------------ - - Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ y Hdirdpan ❑ Adobe " Fill Materi I ------------ 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 kO feet,) [ ] SEPTIC TANK [ ] Size----------------------------- ---------- - ----- Liquid Depth ------ -------------- PACKAGE TREATMENT - • Capacity -- Type Material No. Compartments �T Distance to nearest: Well ------------------------------------Foundation _y_____________ Prop. Line _z------------------- LEACHING LINE [ ] No. of Lines Length of each line---------------------------- Total'"Length ____ :- ,- ---------------- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------------- - -•-------------_----- Distance to nearest: Well ------------------------ Foundation ---------------- ------- Property LinIe ----•------------- SEEPAGE P1T [ ] Depth ------- ----------- Diameter ---------------- Number ----------------------------- Rock Filled - Yes ❑ No i❑ Water Table Depth --------------Rock'�Size 1 . Distance to neargst: Well __.___._-- —__�� — -Foundation ----------- Prop. Line _________-_-•.-__ REPAIR/ADDITION(Prev. Sanitation Permit# _______ ------------------ Date - ----- Septic Tank {Specify Requirements) _} �rif -_ ') �► -- Disposal,Field (Sp.e.c,ify Requirements) - i`- ' .5l1� ,�� -� - ------------------------------------- ( aw existing and required addition on reverse side) 1 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 ------------------ IOwner ----- - ---- - --- ----------------------------- BY Title r (If of than owner) �' ---------------- {� � - 'e------------------------ FOR DEPARTM NT USE ONLY APPLICATION ACCEPTED BY --------- --- -- - -� - ------ --------------------------------------------------- DATE _ BUILDING PERMIT ISSUED _-___---------------- - DATE ADDITIONAL COMMENTS -- ------------ -------- - - --------- ----- ----- - - ----------- --------------- ----------- ------------- -- - ----------------------------------------- ---- ------- �-------�-------- -- -------------'�� - ....... _7� --------------- - --------- --- ------- Final Inspection b ------------------------------ ---------------------------------- -------------------------------------------------------- - P Y- ----- --------------------------------------------------------- - -- -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ` N t