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FOR OFFICE USE. l APPLICATION FOR SANITATION PER T (Complete in Triplicate) Permit No.- �- '__ --•-----------------------------•--------------------- 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 application ismade in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ..�p�If- - _--- ----- _ — --------------------------------- ---------------CENSUS TRACT ------------------ - Owner's Name Address -------C,6 f -- - -•--- Contractor's Name Phone --- . -• ...; License # -f .Z- one == Installation will serve. Residence Apartment House Commercial:❑Trailer Court ❑ 4 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 C] Clay El Peat El Sandy Loam Clay Loam,❑ ------- ----- --- - Hardpan ❑, Adobe❑ Fill Material ------------ If yes, type ---------------------------- � s (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,) E PACKAGE TREATMENT [ SEPTIC TANK.+[ ] Size------------------------------------------------ Liquid .Depth ....--------•-------- Capacity - jype --------------•----- Material---------------------- No. Compartments ----•------- Distance to nearest: Well ------------------------------------Foundation ----------------------- Prop. line -------•- -___--- LEACHING LINE { ] No. of ,Lines ---------------'-------- Length of each line--------------------------------------- Total Length 1 'D' Box --- -------- Type Filter Material -----------_____ ___Depth Filter Material ------------------ •._._.-.................. Distance to-nearest: Well ------------------------ Foundation ---=--____ - ______-__- Property Line SEEPAGE PIT [ ] Depth -----� - - - ----------- ------------ .1 Number ---------------------------- Rock Filled Yes '❑ No .{3 l Water Table Depth ---- ----------------•-----------------« ------Rock Size -------------------------------- Distance ------------------ -Distance to nearest: Well -----------------•----------_---------- - ----------------- ------------ REPAIR/ADDITION (Prev. Sanitation Date ---------------------------------- i Septic Tan'ks,(Specify Requirement's) ------------• ------ ------------------- --------- --------- ------------------- -- Disposal Field (Specify Requirements) -----------------------------i:_ --------'-- ------------------------------------------------------ -- -------•• - i -------------------------------------------------------- �_Q } --------- ------------------ ---------------------------------------------- ------ I(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 ------------------------------------ wrier - O -- .. By --- ------ ----- --- - --- Title ,--- --------- (If other than owner) FOR DEPARTMENT--USE -ONLY- APPLICATION ACCEPTED BY -_,-',L' -_-____-__. DATE _d�". _U-'_T ................ - -- -- - ---------------------------------------------------- BUILDING PERMIT ISSUED ------ DATE ------------------------------------------------------------------- ADDITIONAL COMMENTS --------------- --------------------------------------------- •- - ---------------------- ---------------------- ------------ -----------------------------------7- ------ FinaInspection by. .---- ---------------Date_- p �� SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev, 5M 4