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FOR OFFICE USE: Y "" Q 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 appli ion is made ' co pliance with County Ordinance No. 549 and existing Rules and Regulations: ,�z� P- A ADDRESS/LO ATION . - _sd------ ------ -- ------------1CENSUS TRACT �1.� ---- zc----7�,- _6-- =---- ----- ---t= - �Ys_� Owners Name Phone - �.zu-- Address -// ,�GG --� City i _�-,-`-�---" - �r Contractor's Name ------____-- - -� License # `_ ./73..._ phone __ _ --------------- l Installation will serve: Residence ❑ Apartment House-[D Commercial ❑Trailer Court X Motel ❑ Other ----------------------------------- ------ r i Number of living units/6-7-- Number of bedroo s ------------Garbage Grinder -------'.___ Lot Size------------------------- + Water Supply: Public System and name -__ ___________ � �-- -=---------------- ----- Privafie ❑ ------ Character of soil to a depth of 3 feet: Sand: Silt ❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- r (Plot plan, showing size of lot, location 'of system in relation toells- buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pt.permitted if public sewer is available within 200 feet,j PACKAGE TREATMENT X. SEPTIC TANK�( ]` "" Size------------------"----------.---------------- - Liquid Depth -------------------------- .. ' Capacity �� UU b_� T JL Type .P�"__ Material_L.��- No. Compartments ---------------- Distance --__._............Distance to nearest: Well � S--- !/ _ LEACHING LINE No. of Lines ------------------------ Length of each line---------------------------- Total Length�f _x_w7 U 'D' Box ------------ Type Filter Material Depth Filter Material -f____________________ _____ t Distance to nearest: Well �_X_�--____ Foundation .lD_�1 F --_ Property Line S r - ( SEEPAGE PIT [ ] Depth _----------- ------ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No C WaterTable Depth _!------------------------------------------------------------------Roc Size ------------I--- ------------ Distance to nearest: Well --------------------------------------=-Foundation -------------------- Prop. Line -------.-------------- REPAIR/ADDITION(Prev. Sanitation Permit# '------------------------------------------ Date --------------------I------------ Septic Tank (Specify Requirements) ------------------- --------------------------- ------------------------------------------ ------------------- DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------- --------- ---- ------------------- ---------- ------------------------- ------------------------- --------------------------------- ---------------- ------------------------------------------------------------- ------------ -------- I (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: "1 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 bec e s b),ect tooJWo,kman's C70 = laws of California." Signed -� �! ---------------------- Owner BY -------------------- Title [If other than owner] FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ ---------- ------------------------------------------------------ DATE --- 2. = -21-------------- BUILDING PERMIT ISSUED ----------. 'ee-- ---- . D ----- ADDITIONAL COMMENTS - --------- ---------------------------- --------------- ---------------------------------------------------------------------------------------- --------------------------------------------- --------------------------------------------------- ------------ - - - - ------------- ------ --------------- ------ ------------------------------------------------------------ ----- - ------- ----- --------------------------- -- --- Final Inspection by = ------------------ --------------------------- -Date 1 � ------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M . �,