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FOR OFFICE USE:f" APPLICATION FOR SANITATION PERMIT -- ---=----------------------- Permit No. (Complete in Triplicate) -------------------------------------------- _________________r,_ _----_ This Per Expires 1 Year From Date Issued 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 Ordinancq,,[N .,,5_49 and existing Rules and Regulations: -----------------------CENSUS TRACT ------=--------------- - JOB ADDRESS/LOCATION -_�1--� -----,-----�---- ---��G[-��•� P_ _ --Phone .-.----- Owner's Name --=---��------- �--=�--�---�- ------------------------------ ----------------------�--------------- jj -- City - - - ------------------------------------------------------ Address --•-- -- -- -- - - -��,(---n- ---------------------- � - �J , Contractor's Name -- - -- 1� ' C/L_ `f -----------------------------License -¢--- Phone -� ' Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court i❑ 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 [ ) SEPTIC TANK'[ ] Size- � _ --�-�--- -�------ Liquid Depth -�/ �--.- 4+� ----- Type �Z�GI � Compartments �'�---------- L Capacity � --- yp Material-C�a�n moo. _--- � Distance to nearest: Well ---- t ------------------------------Foundation ___�_P----__--_-_ Prop. Line _ --_- LEACHING LINE [ ] No. of Lines --__-- -_---------- Length of each line---------------------------- Total Length ,____-._-_-_- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ---------:---------------------------------- IQ- Distance to nearest: Well ------------------------ Foundation --------------------- Property :line ---_--------_- - '� Rock Filled Yes No SEEPfrGE—WT [-j- Depth ------ --------- -- Diameter� 'y----- Number ---------_---�- -. � 0 FILT15a 1o" Water Table Depth ----------cP-P------------------------------Rock Size ---;P aiA------------ Distance to nearest: Well ----- ________________Foundation _P_4.'--_--__-_.. Prop. Line ---C�7............... REPAIR/ADDITION(Prey. Sanitation Permit# --------__-------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) -------------------- --------------------------------------------------- •--------------- Disposal Field (Specify Requirements) ---------------------------•--------------------------------------------------------------------------------------------------------- -------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (Draw 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: "1 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 a---- -�nn ---------------------- Own er Title ------------------------ - BY (If other t an owner) (� ` f---------------- FOR DEPARTMENT U4E,' LY APPLICATION ACCEPTED BY ------------------------------------------------ -- DATE -------- ------------- BUILDING PERMIT ISSUED ----------------------- -- - ----------------------- ------- -•"------- -- --- ------- -- -----------------DATE ------------------------ -------- --------- ADDITIONAL ------------•------- --------------------- ADDITIONALCOMMENTS ----------------------------------------------------------- I——----------------------------------------------------------------- --------=-.---------------- ------------- ------------------------------------------------------------------------------------- ------------ -------------------------------------------------------------------------------- ---------------------------------•----------------------------------------------- ------------ -------------------------------- ------ _-- - ------Date -'�"f'�."{�'- -------- ------------------- -- - Final Inspection by- --------------------------- --------- ----------------------------------- --- I SAN JOAQUIN LOCAL EALTH TRI �' E. H. 9 1-'68 Rev. 5M.