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FOR OFFICE.USE: APPLICATION FOR SANITATION PERMIT .,";v � . ..._.. - --- •--- Permit No. +k (Complete in Triplicate) ` ---- --------- ------------ - Date Issued - �- ` ----------- ------- This Permit Expires 1 Year From 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. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION _ Z-J � - -- - ------CENSUS TRACT _X.,-�_-----______ --- Owner's Name ------ -- =1='"'---yam ------ --- --- ---- --- ----Phone--------------- - ✓-5"S 1-;_�" 7(� Address ---------------- City -- 0.1=.� - --------------------- - -- ------------- - ----- -------------------- Contractor's Name ��'-n' "''- + �"C `----. ��? ��r w .License # __Sf F y Phone ------------------- - ------------- 1 Installation will serve: Residence Apartment House❑ Commercial []Trailer Court ,❑ Motel ❑ Other - ----------------------------------- Number of living units:------1_ Number of bedrooms --------Garbage Grinder . - Lot Size __�4_''�` -`� --------- -------- Water Supply: Public System and name ------------------------------------------ ------ --- -----I-------------------------- -----------------Private E �� Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat EJ Sandy Loam - Clay Loam[] Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- F (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) i NEW INSTALLATION: (No septic tank or seepage, pit permitted if public sewer is available within 200 feet,l U PACKAGE TREATMENT { ] SEPTIC TANK;[ ] Size------------------------------------------------ Liquid Depth -------------------------- L, Capacity -------------------- -Type' --------------- Material---------------------- No. Compartments -----------------: € f Distance to nearest: Well -----------------------------------Foundation ---------------------- Prop. Line -------------:-------- ti LEACHING LINE [ ] No. of Lines - -------- --------- Length of each line---------------------------- Total Length ______--__--_-____-..._____ 'D' Box - -- Type Filter Material _________________-_Depth Filter Material -------------------------------------- Distance ________._ t Distance to nearest: Well ----------------- ---- Foundation ---------------------.-- Property Line -----------------....... SEEPAGE PIT [ Depth ---------- ---- Diameter ________________ Number ---------------------------- Rock Filled Yes 0 No i❑ Water Table Depth ------------------------Rock Size -------------------------- - Distance to nearest: Well -------------=---------------•-----------Foundation -------------------- Prop. Line ---_------------------ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----- ----------------- ----------) r , Septic Tank (Specify Requirements} ----------------------------------- -:--------------------------------------------- ------- ------------•.,,------------------------ Disposal Field (Specify Requ'remen ) _Af__ __ � -_- < -_- '` --�___-____ 0 ------ =_ --------- - -- ----------------------------------------------------- --I ---------------------------------------------------------------------------------------- - ------------------------------ ------- ------------------------ --------------------------------------- ----------- -----------------------I --------------------------------- I k (Draw existing and required addition on reverse side) i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin 4 - County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Nome 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 beco a subject to Workman's Compensation laws of California." Signed F ---- - Owner-------------- - - -- - `-------------- Title 1't - ------ ----------------------------- ----- - BY ---------- - - -------------- (If other than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED B ----------------------- DATE _�� u ------ BUILDING PERMIT ISSUED -------------------------------------- -- ------------ ----- DATE.__=---------------------------------------- ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------- ---------------------------------------------------------------- - -- i ---- -- - --------- ------------------------------------ -------------------------------------------- --------------------------------------------------------------- I F ------ ----------------------- ------ -- =----------- ------------------------- - Final Inspection by, -.r----__ - - --- - Date - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M