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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. -------------------------------------------------- (Complete in Triplicate ---------------------------------- Date Issued -------------- This Permit Expires 1 Year From Date Issue and l the work rein Application is hereby man is the Son oin Joaquin ice al ithe Counalth DfiytOrd nan e rict for a permit o549 and �str s=ing Rules tand Regulations. described. This application is m( t��o CENSUS TRACT -------------------------- JOB ADDRESS/LOCATION _"' Owner's Name -- � � ----------------------------- Phone ------------ 011 - Address -- - -- City •----- ---------------------------------------•---•------ Contractor's Name ------- License # _� � y---- Phone _________________ ---- - -------------- ----- Installation will serve: Residence [Apartment House❑ Commercial ❑'Trailer Court ❑ Motel ❑ Other -----------------"------------------------- Number of living units:.---.,r----- Number of bedrooms __-Y__Garbage Grinder --___----__ Lot Size _.._ __f'-�i--at �--,r" Water Supply: Public System an name ______________________ - ----------------- ------ ---------Private LJ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay E] Peat El Sandy Loam ❑ Cla Loam Hardpan F-1Y Adobe ❑ Fill Material ------------ If es, 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,] -- L; uid Depth -------------------------- PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size-----------------------• ------- q p p Capacity --• -------------- Type -------------------- Ma#erial----------------------- No. Compartments ------ •-------- d\ Distance to nearest, Well ------------------------------------FoLmdation ----------------------- -------- -Foundation --------------- ------ Prop. Line ---------------------- 1 LEACHING LINE [ ] No. of Lines ------------------------ Length of each line--------------------- ------ Total Length ---------------------------- --_Depth Filter Material --------------------------------------•--•- 'D' Box -------- -- Type Filter Material ---------- ----- _- Foundation Property Line ------ SEEPAGE to nearest:. Well -_------------------ -- --- -------- " -�--- SEEPAGE PIT [ ] Depth -- Diameter ----- --------- Rock Filled Yes No 0 ------------------ ----- Number - ------ ------- - ❑ — Water Table Depth ------------------------------------------------Rock Size --------------------- -- Distance to nearest: Well ------Foundation ---- Prop. Line --------------------- "--------- -------=•-------------- ---------------- REPAIR/ADDITION(Prev. Sanitation Permit S# ------------------------------------------------------------ Date ----------------------------------) Septic Tank (Specify Requirements) --------------------------"------ --------------------- .--- isposal Field {specify Requirements) ------ ----- : t✓ - -------------------- ------ ------------------------- ud ------------------ ---------------------------------- ---- -- - - -- - - - - - ----------- ------------------------------- (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 performance of the work for which this permit is issued, I shall not employ any person in such manner as to b me subject to Workman's Compensation laws of California." Signed --- -- - ------- - --- ---- -- ---- - ----------L--------------------------------------- Owner -- 7iNe --------------------------------- By (if other than ow er) FOR DEPARTMENT USE ONLY DATE 1'O- "� ('f--------- APPLICATION ACCEPTED BY -----_ DAT ------------------------------------------- BUILDING --- --- ---- ------ ------- ------- -- BUILDING PERMIT ISSUED --------------------- -------------------------------------- ADDITIONAL COMMENTS ------ ----------------------------------------------- -- ---- - -- ------ Date .__.��_-:/�._.-�9.. .. -------- Final Inspection b Z41- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M