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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ 5 e D qq Permit No. .�--f---------------. -----------------------------------•--------------------- : (Complete in Triplicate) --------------------------------------------------- - - ---------------------------------- This Permit Expires 1 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. A �dO6 fJ ` _ .. r CENSUS TR ACT ----------- ----------- ------------- ---------- JOB -------- I a� - - - --------_--_---------- -w--�--.: JOB ADDRESS/LOCATION --------------- ---- -- = _ ------------_ __ er's Name -4 �.. _ City ----� ------- --------------------------------------------------------- Address ----'-519�_C)__ ^- - ------- ------------- - License #1� � __ Phone ------------------------------ Contractor's Name - Installation will serve: Residence Apartment House❑ Commercial []Trailer Court i❑ Motel ❑Other ------------------ ----------------•-------- Number of living units:----- Number of bedrooms __ _-__Garbage Grinder-------------- Lot Size __________--------Private Water Supply: Public System and name ---------------------------=- --- - Character of soil to a depth of 3 feet:. . Sand'[] Silt ElClay E] Peat E] Sandy Loam Clay Loam El I Hardpan ❑ Adobe [] *Fill Material .----'_-- If yes, type ---------------------------- I f f {PI'ot plan, showing size of ion, location-of system in.-eelatio%. 4toww.ells,_buildings, etc. must be placed on reverse side.} t NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,j I Liquid Depth -------- . PACKAGE TREATMENT [ ]. [ q p SEPTIC TANK' 1 ;-Size-------- ---------------------- --------- - N , i Material---------------- ----- No. Compartments ------ ----------- Capacity -------------------- Type ----- � Distance to nearest: Well -------------------------------------Foundation --------------------- Prop. me ___.-------= •------- - Total Len ------- Len % -----••----------- LEACHING LINE [ ] No. of Lines _________________ Length of each line__-___-_-________ _____.- Length _De Depth Filter*Material _____________ 'D"Box -------------- ------------ Type Filter Materia ------------------- p ti Foundation ' Property Line. ------------ -------- ------------- ------- .. Distance to nearest: Well --- -------------------- ---------- -- SEEPAGE PIT [ ] Depth -- Diameter ---------------- Number ------------------- ---------Rock Filled Yes ❑ No C1 Water Table Depth Rock Size -------------------------------- Distance to nearest: Well __-_-______________ ____ ------Foundation l� -- Prop. Line ------------ REPAIR/ADDITION(Prev. Sanitation Permit# _.-------.........-------------------------- Date --------------------------- ------------------ ----=------) Septic Tank (Specify Requirements -------- - ------------------------------ --------------- - ---- --------- -- --- - -- ---------------- ---- --- -------- -------- ------- ffl, Disposal Field pecify Requirements) -- -- , (- - � I -- '�1- - ----- --- -- -- - -- - -- - - - - -- __ ----------------------I -------------------------------------------------- ------------------ ------------------------I---------- ----- (Draw existing and required addition on reverse si e 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. 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, 1 shall not employ any person In such manner ti as to be me subject to Workman's Compensation laws of California." Signed -- -------- Owner Title --:----- (If other than owner} I 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------------------- DATE - - - ------- - ------------------------ BUILDING PERMIT ISSUED -------`----------=--------------------------------- ------------------------------------- --------------DATE ------- ------=----------------- ---------- i-F - -----------------------'------ ------------------------------------------------------------=---------_`-.`-.----------- f ADDITIONAL COMMI ------ --------------------------------------- -i ------------------------- - --- ---------- -- ------------------------------------------- ------------------------------------------------ -' Final Ins ection b - --------------.Date - � -------- -- - - -- ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M