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r FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ' ....... Permit No. ..7 ................... (Complete in Triplicate) .....................................I.. This Permit Expires 1 Year From bate 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-Ordinance No, 544 and existing Rules and Regulations: I JOB ADDRESS/LOCATI N .... ......... :...........-.. CENSUS TRACT .... ...... Owner's Name ... . . ........................... ••. .........Phone' Address .-....... !{.!1r�,Q�i✓ ,rte- ... ....4 City .. Contractor's Name ......- -! -�........ .--?'-- ��License # . 3 } Phone .. Installation will serve: Residence ErAo`partment House Commercial oTraller Court 0 t 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 0 Sandy Loam Clay Loam Q F - Hardpan j] 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 .......................... Capacity --•--------------- Type .................... Material................. No. Compartments ...................... F - Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... LEACHING LINT: [ j No. of Lines ------------------------ Length of each line.............................. Total Length ............................ 'D' Box I Type Filter Material •......Depth Filter Materia( I Distance to nearest: Well ........................ Foundation -------- ............... Property Line SEEPAGE PIT [ ) Depth ....f-------------- Diameter ............I... Number ----.----------------.-.-_- Rock Filled Yes ❑ No Q Water Table Depth ...------..Rork Size ................... Distance to nearest: Well ...........:............:...............Foundation .---------- ....... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ............ Date ..................................} t --•• _ Septic Tank (Specify Requirements} --------------------------------------------- ..------------------•---•---......--------------.........-..........._.--------.__..... Disposal Field (Specify Requirements} ..-- .... .--- t�-- -� �..................... ............•.................. 111)raw 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 W rkman's Compensation laws of California." Signed .... .................. .. .......•-•-----•- ----- .. ..------ --...__........ Owner By --------------------------- c "r ------• Title ... ia (if other than owner) / FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYr-••........................................................ DATE ..^ ......... BUILDING PERMIT ISSUED .....--------- --------------------------------------------:.:---_-----_------_----•-- -----.........DATE ...--•---................-- ......... ADDITIONAL COMMENTS ...:.................... - ......... ........................•--•.................... :.. ......--•-•-----------... ......................... .... .... ....................... .:. ------_.!...................................-.-......................... _ •---- Date - Final Inspection by: -..::.. . .. ..... ......: rl� SAN JOAQUIN LOCAL HEALTH DISTRICT n E. H.13 24 1-'68 Rev. 5M 7/'71 1 K