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FOR OFFICE USE: APPLICATION- FOR SANITATION PERMIT ��, ------------------------- -;-- --- " �- (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 is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: OW JOB ADDRESS/LOCATION 1 ----- J-- -------- - ..._CENSUS TRACT --------------------_--- Owner's Name ---------------------------- --- -- ---- --------- ---- -'t--- ------------------------•-------- hone Addressf - -- ------. City --- Contractor's Name �; � -- License #1 ------- Phone Installation will serve: Residence XApartment House❑ Commercial ❑Trailer Court ;[] r Motel ❑ Other ------------------------------ Number of living units:____r__-_ Number of bedrooms _Garbage Grinder ________ Water Supply: Public System and name __________________ -----------------r--------------------------------------------- -------------- ------Private ❑ Character of soil to a depth of 3 feet: Sand'E] Silt E] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan C] 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 ------ ----- -- Distance to nearest: Well ---------------------------_--------Foundation ---------------------- Prop. Line ----------- .......... LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ____________________________ 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------._._-------------------------- Distance to nearest: Well __________________ ____ Foundation ------------------------ Property Line _______._.-__.___.....__ SEEPAGE PIT [ ] Depth -------------------- Diameter ----_.__--------- Number ----------------- Rock Filled Yes ❑ No Water Table Depth ---- ---------------`-----=-----------Rock'Size ------------------------ Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ________..____._...... REPAIR/ADDITION(Prev. Sanitation Per 't# -------------------------------------------- Date _________ _____________-___-_--.__) Septic Tank (Specify Requirements) _ _ ________ _ ___ -* _(( ''t -o---_-- - � G Disposal Field (Specify Requirements) ----- G ------ �I 33�rkms------r - , - --------------------------- ------------------- ------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------- (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 Son 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 -------------------------------- - Owner �^ By ------- ----- `Title ----- ' 7 - -- - --- --------- - (if othe n owner) FOR DEPART"T USE ONLY APPLICATION ACCEPTED DATE _. _/7 7Z- ------------------------ BUILDING PERMIT ISSUED ----------- -------------------------------------------DATE - ----------- ----------------------------- ADDITIONA-L COMMEN -g-=Ay`7 --------------- 7=�-=----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----- --- ------------------------------- --- - - ---- ---- - ----------------------- ------------------------------------------------------- ------------------------------------------- --- ---------------------------------- =-- =- ------------------------------------------- ----------------------------------------------------- --- FinalInspection by: _ .• --- - - ------------------------------------" ----------------------------------------Date ------ SAN ----SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M