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FUR OFFICE USS: A ICATION FOR SANITATION PERMS _ ------------------------ .. -------- Permit No. ...��- S1� (Complete in Triplicate) _------------------ ---------= This Permit Expires 1 Year From Date Issued Date Issued ._- ..7./ 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/LOCAT N .-.----- ---- /.---- - ------ ..... ---c 6 ._.. __ CENSUS TRACT --.---------------------- Owner's Name ------ ---- --- - ..--.t. Phone _ Address City - �Y�- --------- ---------- - ------------- Contractor's Name ------ -------- ..... __._.License #p2,s -/I2 Phone Installation will serve: Residence ❑ Apartment House❑ CommerciaXrailer Court ;❑ Motel ❑Other -------------------------------------------- Number - --- ---------------------------------- 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❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobex 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.) V 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 O Water Table Depth --- ------------ -------------------------------Rock Size ------------------------ Distance to nearest: Well ........................................Foundation -------------------- Prop. Line .-__----_--_------- REPAIR/ADDITION(Prey. Sanitation Permit# ............................................ Date --------------------.------------.) SepticTank (Specify Requirements) ----------------------------- --------- ----------------- -------- ------------- --------------------------------------------- --------- Disposalr Field (Specify Re uirements) ....................... ........................+__.____.. . -......- ---- ---- �--- Via - (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 perfor ante f t e work for 'ch this permit is issued, I shall not employ any person in such manner as to bete su 'ect,to o ma 's C�ompeniatidgla s of California." Signed --- - -----*---- --- .2L_c - --- ------ Owner BY ''.. ....... Title ----------- ---_. -- ----- .....--- ...... -- -- (If o an own r) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --N --------------------------------------------------- -- --------------- DATE ------(c7 ---- - -- - - - - -- --------------- BUILDING PERMIT ISSUED ---- -=------------------------------ ---------------------------------- ----------------- -------DATE .--- --- ------- ----- ------------- ADDITIONAL COMMENTS --------------------------------------------------------------------------- ------------------- ------------------- ---- ---------------------- ----------- ----------------------------------------- ----------------------------------------- ------ -------- -----------.... - --------- ---------------------------- -- - ---- - ------------------------------------ ----------------------------------------------------------------------------- - - - . ------- ------------- ----- -- ---- -- ----- - -- -Final Inspection by: -- --- ---------------------------------------------...--------- ----------- ------------ - -Date . V - -------------------- SAN - - ---- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M C