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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. --0-/---------9 ---------------------------------------------------------- This Permit Expires T 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/LOCATI ---------------CENSUS TRACT -------------------------- Owner's Name ------- y --- - -------rte ------- --------• ---------------------------- Phone Address ---7 1 r . City - l• -�- Contractor's Name - -- - ------------------.License #,16i�-1-2 Phone Installation will serve: Resi ence Apartment House❑ Commercial❑Trailer Court i❑ Motel ❑Other -------------------------------------------- Number of living units:._..------ Number of bedrooms -.I-------Garbage Grinder ---E1------ Lot Size -------------------------------------------- Water _________________ __ ___Water Supply: Public System and name ---------------------------------•-------------- ---------------------- ---------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay Peat❑ Sandy Loam ❑ Gay Loam ❑ Hardpan ❑ Adobe ❑ 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 side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ l Size----------------------------------- _______ Liquid Depth ---------------- Capacity - -------------------- Type -------------------- Material---------------------- No. Compartments --------------- • --•- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -----..-_....__.......J LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length _-___-__---.__--•--.•-__------ 'D' Box ------------ Type Filter Material ------------- ------Depth Filter Material -------------------- ....................... Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ----------------- ...... rn r SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth ---- ---------------------------------- -------Rock Size -------------------------------- ;r_to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------.._.---.-.-5 REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) SepticTank (Specify Requirements) ------ -------- ---------------------------------- -------- ------------ •----------------------------- Disposal Field (Specify Requirements), _�____ _____ �` / 3 ��p x e- --------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------------------ (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 become subject to Workman's Compensation laws of California." Signed --------------------------- Owner BY ----- —- -- - /-i'�1 �---------------------------------------------- Title ----- -- - 1----------------------- ------ - -- (If other tha owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE _ - ---------------- BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ------------------------------------------- ADDITIONAL COMMENTS -----------------------------------------------------------------•----------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ------------------------ - a --- ----------- ------------ T --------- --- ------ ----- -------- ------------------------ Date Inspection by: SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M