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FOR OFFICE USE: - ------ APPLICATION FOR SANITATION PERMIT --- � �� Permit No. ---- --------- - (Complete in Triplicate) Date Issued --- 0 ----`-----------------------------------------------_--- 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 -------- ---.CENSUS TRACT __________________ _ ____ Owner's Name -. ----------------------------/-- ---------------------PhoneG��' � Address ------------------------------ ------------ city ^� �j 14 ------------------------------_---•-•-- Contractor's Name_ 4_--- e...........License Phone Installation will serve: ) Residence)(Apartment House^❑ Commercial ❑Trailer Court ;❑ I Motel ❑Other ----------------------------- -- -- Number of living units:-----i----- 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[I Sandy Loam ❑ Clay Loam Hardpan ❑ 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.] UI f NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) �! PACKAGE TREATMENT [ ] SEPTIC TANK;[ ] Size___ ~.X__9________._________________ Liquid Depth �--__-----_______ Capacity _______ Type _____ Material__.( ____ No. Compartments Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ----------- LEACHING LINE [ ] No. of Lines ------Z------------ Length of each line__ a-______________ Total Length 'D' Box _37----- Type Filter Material -,�G"�_Depth Filter Material __-1 __r___________________________ Distance to nearest: Well ________________________ Foundation ------------------------ Property Line. ------------------------ SEEPAGE PIT [ ] Depth _�.��_-_-_ Diameter _K3----- Number _____-__Z___.__________ Rock Filled Yes No ❑ WaterTable Depth ----------------------- ------------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ________-._______-__--'�R+.. REPAIR/ADDITION(Prev. Sanitation Permit=# --------- ------ Date --------_--•----------------------) SepticTank (Specify Requirements) -----------------------------------------------------------=-----------------------------------•---------------..--------------------------- Disposal Field {Specify Requirements) -------------------------- -------------•--------------- ti ------- ----------------------------- -------------------------------------------- ----------------------------------------------------------------------------------------------------------- -----------------`------------------------------------------------------ -------------------- (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 Loca'I Health District. Moate owner or licen- sed agents signature certifies the following: k (—) "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." s SignedOwner BYt ------------------- -- - - Title d .............. ------------------. �_ __,lf_other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY + -------------------------- DATE _�'� L- 'J7 ------------- BUILDING PERMIT ISSUED ----- ---------`-- ----------------------- ---DATE ------------------------------------------- ADDITIONALCOMMENTS -------------------------------------------------------- ---•---------------------------------------------- ---------------------------------------•----------- ------------------------------------------------------------------------------------------------- ---------------------------------I-------------------------------------------------------------------- ---------------------------------- - --- -------------------- -- ------------= -- Date ------------------------------------------------------------------ --- ----- ------ - -- ---- Final Inspection by: Q SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M