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=FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT r ------------------ ----------- - b 7 (Complete in Triplicate) Permit No. _-------_-__-------------------------------- 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: JOB ADDRESS/LOCATION _ ---'f-- ------------------------ ---- -.CENSUS TRACT ---..---------- Owner's Name -- ------ I ---------------------------------------------------- ---------------------Phone ------------------------------------ Address � --------- --------------------- City Contractor's Name --�----------------------------------------------------------------License # ------------------------ Phone --------------------------- Installation will serve: Residence ❑ Apartment House[] Commercial ❑Trailer C,6"a Motel ❑ Other ---------------------------------------- Number of living units:____------- Number of bedrooms ____________Garbage Grinder ------------ Lot Size _47'4__i_____________________ _ ' Water Supply: Public System and name ---------------------- ------------ ----- -- _----------------------------------------------------------------Privatel' Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay 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 i public sewer is available within 200 feet,) �1 PACKAGE TREATMENT { ] SEPTIC TANK.] Size_— - ��_f'�_________.___ Liquid Depth .--7--_________ Capacity lZ_ _____ Typ _ Material__Ci'?---------- No. Compartments __� ..... ........ Distance to nearest: Well trd' ___________________Foundation _140 --*I------- Prop. Line __ri........... LEACHING LINE ] No. of Lines _-__ --------------- --______._____ Total Length ,_f� _..__.____-_ Length of each line_____-_ _ g __. 'D' Box Type Filter Material .4'�9_/k------Depth Filter Material ---------_____________________ Distance to nearest: Well ---040"o ---I--- Foundation _/0_` ........... Property Line----------------- SEEPAGE ine_ _____________SEEPAGE PIT Depth -Ar------- Diameter -------- Number ------ ------------------ Filled Yes E& No 0Water Table Depth __/2__$7--------------------------------Rock Size -/___'.../-------------------- i Distance to nearest: Well ...}..................Foundation 199------1...... Prop. Line ................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) ------------------------------------------------------------------------------------------------------ - • ---------------------------- Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- -- --- - ------- ------------------------------------------------------------------------ ------------------------------------------ _------------------------- ---- ------ - - ------ - --- - -- - ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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 su 'ect to Workman's Compensati/on laws of California." Signed -- ------------------------- Owner BY -•------------- / - -Title ---------------- ------------------------------------ --------------------------- ----------------------------------------------- (If other than owner) Ot FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _- DATEf'7�_____________ BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE - ------------------- --------------------- ADDITIONALCOMMENTS ------------------ ----------------------------------------------------------------------------------------------------------------------------------------- - ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------- Final Inspection by- Date ", -, may- SAN JOAQUIN LOCAL HEALTH DISTRICT W E. H. 9 1-'68 Rev. 5M