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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ ---------------------------------------------- - {Complete in Triplicate) Permit No. IThis Permit Expires 4 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 e in compli rice with County Ordinance No. 549 and existing Rules and Regulations: described. This application is mad JOB ADDRESS/LOCAT _ F-`-"`_.....----c -71Z -.-.__CENSUS TRACT -------------- - Owner's Name _. ""-` - iii ----------- -- Cit Address ----- V ---------- Contractor's Name -------- __---- � � _ __-- .License # " __ - ------------------•------ -- -- -------- - - ------ -- i �� '�-Phone ----- ---------- ------------ Installation will serve: - Residence Apartment House❑'Commercial '❑TraileVCourt ',❑ " '" 4- -- " 4 Motel ❑Other Number of living J . g�units:..__/____- Number of bedrooms .4 Garbage Grinder ""_________ Lot Size _.�'"�__-.______- Water Supply: Public System and name ---___---__"-__"---""_-_--" - " -.- - ----------- • - - - ------- ---------------- ------•-------------------- - -------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay I] Peat❑ Sandy Loam r�] Clay Loam ❑ 4 Hardpan E] Adobe 0 Fill Material _ es ' "- ---."_ If yes,type-------------=------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placedon reverseside.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 2001 feet,) PACKAGE TREATMENT [ 7 SEPTIC TANK ^-- Size_ -______ - I -- --------- ------------- Liquid Depth -------------------------- Capacity -°------------------ Type -------------------- Material -------------_--------- No. Compartments p ---------------•-:---- Distance to nearest: Well ------------------------ -----------Foundation ----------------__-"-- Prop. Line ----------.---- ""__-- I LEACHING LINE [ ] No. of Lines -' .L .} Length of each line- ---------------.�------- Total Length ---------------------------- 'D' Box ------------ Type Filter Material_'_'4_`r x --_-_-_Depth Filter Material .----------Distance to nearest: Well "___-- Foundation ___.-----_.-" Property Line .. -------••------------•- SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number -------.------? Rock Filled Yes ❑ No i❑ A Water Table Depth ---------- -- -__-- Rock Size ' -------------- - - Distance to nearest: Well -------------- Foundation ---- ----- ---- Prop. Line -------------- ---------------- REPAIR/ADDITION(Prev, Sanitation}Permit# -------- -------------"___--._ __-_"__.---__ Date�X } --------------------- Septic Tank (Specify Requirements) ----__-_..________ _____________ Disposal Field (Specify Requirements) --- ------------------ ISO ----------------------- 1 --- (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 ollowing:"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 beta e s ject to Workman's Compensation laws of California." Signed Owner ----------- ------------------- Owner ---- ". Title -------- F (If other than owner) -------------- FOR .DEPARTMENT USE ONLY # APPLICATION ACCEPTED BY -._ __--_ ----------------------------------------- DATE --� ------- ILDING PERMIT ISSUED -------------- ----------------------------------------------- ---- ADDITIONAL COMMENTS ------ ------- DATE - - ---------------------- -�� ------------- -------------- - { - ------------------------------------------------------------------------------------------------- Final Inspection by: "__- .--_-- - - v ---- - --------- ----------------------Date �?.-/ x - ------------------------------ SAN JOAQUIN' LOCAL HEALTH DISTRICT 1 E. H. 9 1-'68 Rev. 5M