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t ------------ - FOR--OFFICE- ,USE- ----------- Permit No: : APPLICATION FOR SANITATION PERMIT n -- ---- -- -- --- (Complete in Triplicate) �` ------------------------------- �' b-��V ---------_ This-Permit Expires 1 Year From Date Issued Date issued __.---_-_________-- Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliaajn�cee with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESSILOCATIO 1111P AJ � " �_1 - CENSUS TRACT ------------------------- Owner's Name ----- -----------•------------------= = Phone_------------------------------------ - K City -- Address --------------- - '� ------, Contractor's Name `= ' -- --------------License# _!_ �_ Phone Installation will serve: Residence Apartment House Commercial❑Trailer Court El Motel ❑Other-------------------------------------------- Number of living units ---- Number of bedrooms ________Garbage Grinder ------------ Lot Siz Water Supply: Public System and name --------------------------------------------------------—---------------------------------- -------------Private Character of soil to a depth of 3 feet: Sand E] Silt[I Clay [I Peat E] Sandy Loam Clay Loam.❑ Hardpan ❑ Adobe 1] 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 sidel _ NEIN INSTALLATION. (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) PACKAGE TREATMENT { SEPTIC TANK I I Size------------------------------------------------ Liquid Depth ----------_-_-------------� Capacity -------------------- Type ------------------ - Material---------------------- No. Compartments -----------------=--- i 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 -------------------------------------=---- I Distance to nearest: Well ----------------------- --------------------- Foundation ------------------------ Property Line. ------.----------------- SEEPAGE PIT [ I Depth -------------------- Diameter ----------------- Number ---------------------------- Rock Filled Yes [] No 0 Wager Table Depth ....................................... -- -------- ------------------------ ----Rock Size -------------------------------- Distance to nearest: Well.--------------------------------------Foundation --------------- --- Prop. Line -----------.-.----_- REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------ --- Date -----------------------_-------) Septic Tank (Specify Requirements) --=--------------------------------------------------------------------------------------.=-------------x--------------------------- Disposal --------------Dis sal Field (Specify Requirements ------------------------------------------------------ -- ---- ----- ---------- ---------- -- - �� r ---------------------------------------------------- --- - ----------------------- - _ --------------------------------------- --------(Draw existing and required addition on reverse side) 1 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. Hance owner or licett- 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 maneter as to become subject to man's Compensation laws of California." Signed ------------------------ ---- --- ------------ -___ Owner Title {if other than owner) 12 FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- - ----- -- �---- ----- --- -------------------------------------------- --'----- DATE -----�--� 7-----------------•- BUILDINGPERMIT ISSUED -------- --------------- --- ---------------DATE ---------------------------------- -------- ADDITIONALCOMMENTS -------------------------------- --- --- --- ----------------------------------------------------------------------------- ---------------------- ----- - ---------- - -------------------------- -- - - ( - ------ - --- Final Inspection by ---------Date- 7 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.