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FOR OFFICE USE: = APPLICATION FOR SANITATION PERMIT � ------ --- ` .......ij (Complete in Triplicate) Permit No: ----.______._____________----- This Permit Expires ] 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: JOB ADDRESS/LOC ION .._ _ _ � -y _ w " !�r° -- -- --- - ------ ----=-------- CENSUS TRACT ,. - ---- - Owner's Name ___ __--- ------•------------ Address _ �+ `+ �' -- - G .City ----- ------------------- � . / Contractar's Name ________ -�---_- _---- .----License #Zff-. __ - Phone -------------------- ._ Installatibn Will-servti: "— "•'- ••Residence Apartment-House,0.Commercial.-:8Trailer-Court=;❑ - f.A Motel ❑Other -________---------------------------------- Number of living units: ---- Number of bedrooms ,-Garbage Grinder Lot Size --- ______... ...... Water Supply: Public System and name ___------------------------------------------o __--_----_--__-Private [ z Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑� Peat❑ Sandy Loam _ Clay Loam ❑ Hardpan ❑ Adobe E] Fill Material )`tV_ If yes, type _________________________ -- r (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 f ] Size_____ = ----------- Liquid Depth -----------•-------- CapacitY ------------------- Type -��"'w. aterial No. Compartments .--------------------- Distance to nearest: Well _ , __-----_____Foundation ______________________ Prop. Line __----_______ ........ LEACHING LINE [ ] No. of Lines ________________________ Lengthlbf each line----------------_----------- Total Length 'D' Box ----- ------ Type Filter'-Material ____________________Depth Filter Material __-_________ __ Distance to nearest: Well w------------------------ Foundation -------- --------------- Property Line ----------._ SEEPAGE PIT [ ] Depth _.._---'._ '•- Diameter ________________ Number ---------------------------- Rock Filled Yes Q No 0 T Water Table Depth --------- ------------------ -------Rock Size ------------------------------- Distance to nearest: Well ---------------------------------------------------- -----Foundation --------------- ---- Prop. Line -------•-------------- REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date -------------_----------_. __---_-) Septic Tank (Specify Requirements) ------------- rt— Disposal �i -- . Disposal Field (Specify Requirements) __ __________ -- ------- ---------- - --`---- --- Z-+---------------------------- -- ---------------------- ---- - -------------- ----------------------------------------------------------------------------------------------------------- -------------- raw 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 performance of the work for which this permit is issued, I shall not employ any person in such manner as to become su 'ect to Workman's Compensation laws of California." Signed ------------- - ---------- ----- Owner -- ----------------- Title --- ------------ s -- - - --- -- - - ----------------------------- (If other than owner) FOR DEPARTMEN USE ONLY APPLICATION ACCEPTED BY------ --1- ,_ _--- --------- -- DATE --��---- --- ------------------ - -------- ---- BUILDING PERMIT ISSUED -------- ------ -----------------DATE .. ADDITIONAL COMMENTS - - ----------------------------------------------- -------------- -----=----- ---- -------- --- ---------------------------- ---- - ------------ -------------- -------------------------------------------------------------------------------------------------------------------------------- ------- ---- - - -- ---- - Final Ins pecfiion by. -------------- --- ------- ------------------------------------------------- ------------ --- -- - --- - ------ -------- --f----------------- ----------------------------------------------.Date --- -- ------------------. SAN JOAQUIN LOCAL HEALTH DISTRICT r E. H. 9 T-'68 Rev. 5M {