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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------P `r (Complete in Triplicate) -�f��f�__®'�.y Permit No: Date Issued A This Permit Expires 1 Year From Date issued Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in co pliance with County Ordinance No. 549 and existing Rules and Regulations: -� --- -------- ------CENSUS TRACT _.---------------•-------- JOB ADDRESS/LOCA' N _N. _ / -- -----------�----- - ' - -- ----------- - - Name _ - -------------------Phone ------------------------------------- Owner's Address -_. City ---------------------------------------------------•---------------- ------- Contractor's Name License # ---------:-------------- Phone -----------------------.---•-- Installation will serve: Residence eApartment House❑ Commercial ❑Trailer Court [I Motel ❑ Other ----------------------------------------•--- Number of living units:--/-------- Number of bedrooms -1— GrinderW------ Lot Size - - - /l- -- ------•---- Water Supply: Public System and name ------4:1-11y--------------------------------------------------------------------------------------------Private _---_ PrEl ivate F]Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay-E] Peat ElSandy Loam 0Clay Loam Hardpan E] 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 f ] Size--------------------------------------- ------- Liquid Depth --------------- - -----. \\ CapacityT ---------- >-- e -------------------- Material--- -----.-------- No. Compartments ---------.. -------•-- v - YP - Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -------------=------- LEACHING LINE [- ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ----------- ................. 'D' Box------------- Type htW_Material --------------------Depth Filter Material ------------------------------------•-- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. ---.-------------------- SEEPAGE PIT [ ] Depth ____ Diameter ________________ Number ---------------------------- Rock Filled Yes '❑ No WaterTable Depth ------------------------------------------------Rock Size -----------------------•------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -----•-. ------------ REPAIR/ADDITION(Prev. Sanitation Permit# _...- --/--�------------------------------- Date -----------------------------.----} Septic Tank (Specify Requirements) -------- ---------------------------------- -----------4---- -- Disposal Field (Specify Requirements) ____ _ - 3_ --- ;- 4 K� -------------------------------------- ------------------------------------------------------------------------------------------------- (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, 1 shall not employ any person in such manner as to b ------------ecom e;t tkRofkmman's Compensation laws of California." p / " Signed ._ - ---- ------- - ------------------------------------------------------- Owner - BY r ---- ----- ---------------- Title ------ -------- ! (If other than wrier) k FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------`--7- ----------------- ----------------------------------------- ----------------------. DATE __._�� :<` BUILDING PERMIT ISSUED -------------------------------------------------- -------DATE ------------------------------------ ADDITIONAL -------------------------------- pADDITIONAL 'COMMENTS -------------------- -- ------------------------------------------------------------------------------------------------------------------------------------ ----------------------- ---------. Final Inspection. b Date ------------ -- -- -== ---- SAN -JOAQUIN-LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M