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FOR OFFICE ------------------ =-- � �. APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit ------- ----- --- -------- 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 workAetein described. This application is made in compliance with County rdinance No. 349 and existing Rules and Regulations: JOB ADDRESS/LOCAO - . ------------CENSUS TRACT Owner's Name -_-- = __ __ _____________ ---- Y - -----------P one ------------- ------- ---------- Address __ ' Contractor's Name City- - • License # = Installation will serve: Residence Apartment House❑ Commereia!:❑Trailer�rt7,,❑ Phone Mote! ❑Other Number of living units:______-_--- Number of bedrooms _______Garbage Grinder ---------.-_ Lot Size 49�-1 Water Supply: Public System and name --------------------------------------------------------------- ----------- -----------------------•------------•------ --• Private Character of soil to a depth of 3 feet: Sand I-] Silt 0 Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam�� , Hardpan ❑ Adobe•❑ Fill Material ------------ !fes, t Ytype --------------------------= (Plot pian, showing size of loft, location of system in relation to wells, buildirigs'„ etc: must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if,public ` sewer is available within 200 feet,} # Al PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size ' _ A , -------------------------------- Liquid Depth ---------- --- Capacity -------------------- T -----!Material------------------------.. -No!'Compartments ------•- Type ------------- n Distance to nearest. Well ____________ _ LEACHING LINE Foundation --------------------- Prop. Line __ -- ----.------------ [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ------------ _- I--------- 'D' Box ------------ Type Filter Material __________ _________Depth Filter Material Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line .+ -._ __ t SEEPAGE PIT _ - - - ---••••-•----- [ ] Depth -------------------- Diameter --- Number --------- �-� .-: ------ ------ - _____ Rock Filled� Yes ❑ No 1❑ Water Table Depth T .4 - ---- --- -------- ------------------- Rock Size -- Distance to nearest: Well ___ -Foundation _' Prop. ;Line ------------ ____.___ __._...•_-• REPAIR/ADDITION(Prev. Sanitation Permit# ------- -------- -------------------------- e -_ __ -- # Date ------------ Septic Tank (Specify Requirements) --------------_________ --------- --------------------------- - --- + --- ------------------------------------- - Dis osal Field S ecif Requirements) -------- ------------- -- ----------- - ------------- ------------ + ------ _-------------------------- ------- -�------- A (Draw existing and required addition on reverse side) -----------------------------� ; -------- I hereby certify that I have prepared this application and that the=wor will be done in accordance 'withSanJoaquin County Ordinances, State Laws, and Rules and Regulations of the San'Joaquin Local Health District. Home owner or licend sed agents signature certifies the followlns c ! "I certify that in the performance of the work for which this permit is issued I shall not employ an " ' i as to beco a sub'. ct,to,,Wo kman' Compensatio- - n s of California." P y y Person' n such manner Signed _. _._- I -- -- v --- -- -- Owner ------ - - - Title --------- ------ ----- (If other than owner] --------------------------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- ----- --------------------------- DATE BUILDING PERMIT ISSUED ADDITIONAL COMMENTS -- --------- - ------- - --- -------- ------------------ -------- - �---- ---- - --------DATE ---------------------- v ------------------------------------------------------ ----------- l r ------------------------- --------------------------------------------------------------------------------- - ----- Final Ins ection b P Y - - ---=------- = ------------------.--Date --- - ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT Ft . ' E. H. 9 1-'68 Rev. 5M f