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FOR OFF CE USE: 1 A/M - _ APPLICATION FOR SANITATION PERMIT --C-'7— ----- ---------------I_ (Complete iPermit No: --------------.------ n Triplicate --------- �_ ----------'� Date Issued C ` - ---------------- --------------------. 1- This Permit Expires 1 Year From bate Issued _ II 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 Ord- n e No. 549 and existing Rules and Regulations: - CENSUS TRACT JOB ADDRESS/LOCATI _h_. __ ---•, _-� /- Owner's Name _ r.. "1 / -----Phone ------ / 7 Address ._.._ ---------------------------City Contractor's Name -.___-- �! {� - - = License #I6' / -Phone Installation will serve: i Residence [Apartment House,❑ Commercial :❑Trailer Court i❑ Motel ❑ Other ---------- ----------------------------•--- Number of living units:-------1V- Number of bedrooms --__Garbage Grinder_- Lot Size ae -------------- Privae Water SuPP!Y� Public S System! name ------------------------------------------------------- l Character of soil to a depth oiif 3 feet: Sand'❑ Silt❑ Clay r-1Peat❑ Sandy Loam ❑ Clay Loam [I itHardpan ❑ Adobe Fill Material ------------ If yes, type ____________________ A (Plot plan, showing size of.iJlot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (Nol septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK'f ] Size--------------------------A-------------------- Liquid Depth -------------------------- Ca acit Type -------------------- Material----------- ---------- No. Compartments Distance to nearest: Well ------------------------------------Foundation ------- -------------- Prop. Line ------------- ------ f LEACHING LINE [ ] No.11 of Lines ------------------- ---- Length of each line.....----------------------- Total Length ---------------------------- -D'O�13ox ------------ Type Filter Material --------------------Depth Filter Material ------------------------------•------------- Distance to nearest: Well ------------------------ Foundation ----------------------- Property Line -----------------,-=---- , SEEPAGE PIT [ ] Depth Diameter -____-_____ Number _____._"--------------" -- Rock Filled Yes E] No i❑ - --- Water --------- ------er Table Depth --------------------------------------- --------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------------.-------- Data } REPAIRfADI]1TION(Prev. Sanitation Permit# ----------------- f Septic Tank (Specify Requirements) -------- ----------- -------- � " �� k 1011` -------=------------------- ------ Is Disposal Field (Specify requirements) ---- - -•-------/---------- E'= 1 x 1 ---- -------------------------------------- ----- -------- -------------- - -- -------------------------------------------- ----------------------------------------------------------- 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 hi accordance with San Joaquin 4 County Ordinances, State Laws, and Rules and Regulations of the. San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the fallowing: 4 "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 become subject to Workman's Compensation laws of California." Signed ----------------------------------- --- ------- - Owner BY ------- -------------- --------------- Title -------- ------------------------------------- (lf other than'ow 1 EPAATMENT USE ONLY T APPLICATION ACCEPTED BY ------------ --- -- - DATE - BUILDING PERMIT ISSUED11"-----------= -- -- ------------------------- -------------------------------- DATE ------------------------------------------- - - -- --- ---- ADDITIONALCOMMS TSN---------- - - -------------- -- --------------------------------------- ---=--- ----------------------- -------------------------------------------------------------- �` --� t- ------ r- -------- -------------- -------------------- Final Inspection b f ' �- - --- -------------------------------------------------------------------------- ----------------------- ----------- -------- P Y: --------- ---- -- -- -- - Date f^ k S�OAQUIN LOCAL HEALTH DISTRICT I E. H. 9 1-'68 Rev. 5M.':. i