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- i FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT / 3 ---- -- -------- ----------•--------------------- Permit No.. . � ' - -------- ---------- ---- --------------------- (Complete in Triplicate) ------------------- This Permit 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 a lication ' made in c rrvp !once it C my Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LO AT 7 -. -------- __ - _:_ ENSUS TRACT -------------------------- Owner's Name - - Phone ------------------------ --- Address ------ -4 City y �` _ Contractor's Name ----- - --____-- =--z /__.- --------------License #/Z/751- Phone --------------------------•-- Installation will serve: Residence Apartment House,[] Commercial :MTrailer Court 0 Motel ❑ Other ----------------------------------------- Number of living units:---- ------ Number of bedrooms _______Garbage Grinder ---------- Lot Size __________________________ ________________ Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private [ j 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,) or PACKAGE TREATMENT SEPTIC TANK' Size-___ _ S { � ��-�X--�-�-------- - ---------- Liquid Depth -�_--, - - --------------- \' Capacity ---1.2DO • Type ------ - r- Material-- i i -- No. Compartments �'� - V` A 11 Distance to near Well _.__ �'________._______..Foundation ___IV._�_____.___ Prop. Line .... ......:........ LEACHING LINE [�(j No. of Lines ______ ___________ Length of each line------APO............. Total Length -- 4 'D' Box .__ Type-Filter Material •r' __ ,_______Depth Filter Material -----0--_--- Distance ly nearest: Well --------- Foundation --------!.S?_°........ Property Line __f___`_____________ ______ Number ------c--- ------___ Rock Filled Yes No SEEPAGE PIT [� Depth ___-.�_�______° Diameter ___ 33 Jr `� �❑ Water Table Depth -----------------r�40--------------------------Rock Size Distance to nearest: Well ------------JQo-------------------Foundation ------l0......... Prop. Line _.'�..--..___.-----_ G REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------_-----------.----------) 1 SepticTank (Specify Requirements) --------------------------- ------------------------------------------------------------------------------------------------------------ ! Disposal Field (Specify Requirements) ------------ ---------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------ (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 subject to Workman's Compensation laws of California." Signed -- ----- -------------------- Owner - --------------- By - .----- ---- -- ------ Title ------------ - - .2ttt 1 - ---------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY : ---------------------------- ----------------- ----------------- DATE ------------- BUILDING PERMIT ISSUED ----------------------------------------- -------------------DATE -------------•----- ADDITIONAL COMMENTS --------------------------------------- --------------------- -------------------------------------- ------------------------------------- --- ----------------------------- ----- `------- - ----- - - - - ------ - -- Final Inspection by: _. Date _-- --+� ------------------------------------------- ------------- -- ---- --- ----- - - I SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M 1