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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------ ----------------------- (Complete in Triplicate) Permit No: ._ >--'---5 ---------------------------------------------------- _____________________ _____ This Permit Expires 1 Year From Date Issued Date Issued --- Application 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 Count Ordinance No. 549 and existing Rules and Regulations: �e � V JOB ADDRESS/LOCATION .____ L,----------- f _ ________ --------------- -- ---- ----------CENSUS TRACT -------------------------- c!f Owner's Name -- ---- ----- ----- --- -------- -------- --------------------:---------------- ------------------.Phone -T a � ------ I Address ---------------- _ - . - - - - -- ----- -------------- City ----- -- - -- - - - -- --------------------------------------- 1-44 --------- - --•-------------- Contractor's Name ---_-- --------P------------- - ----'�--�- =��l--::-------.License #�� -�-------- Phone ."7-��_'l�(l.�_, d Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other _ ------------------------------ Number of living units:------/---- Number of bedrooms ___ -Garbage Grinder ____ otSize ____ __ J__ ,___-________ Water Supply: Public System and name ------------------------------------------------------------- -------/------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand' Silt —,'Clay Peat Sand Loam Clay,Loam p ❑ ❑ Y D ❑ Y ❑ Y' ❑ 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'[ ] Size-------------------------------------------- -- Liquid Depth -------------------------- Capacit.y -------------------- Type -------,.------;:__-- Material---------------------- No. -Compartments Distance to€nearest: Well ---------_._______`___'T______________Foundation -_{__ Prop. Line ____________.._.___.__ LEACHING LINE [ ] No. of Lines ________________________ Length of each line--------- ----------- Total Length ---------------------------- -7 __ _--_______-__-------_--_•__-, 'D' Box ------------ Type Filter Material ____________________Depth Filter Material -------------------------------------------- Distance _.___-_________--.______-•-_--__-. ---.Distance to nearest: Well ------------------------ Foundation ____________________ Property Line _______________-__--____ SEEPAGE PIT Depth -- Diameter Number---------:-------------------- Rock Filled Yes El No t Water Table- Depth -------------------------------------------------Rock Size ----- - ------------------------ ~ 1. Distance to nearest: Well ---------------------__-__:_--.._-___._.Foundation -------------------- Prop. Line _.__.__._____.__..___. III REPAIR/ADDITION(Prev. Sanitation Permit# -------______`_---------------------------- Date ----------------------------------I Septic Tank (Specify Requirements) ____________________ __ _ - -------- -- ------ --------------------------------- ---- _ rr L ------------------------------------ Disposal Field (Specify Requirements) ----------- -------------------------- -------------- -------------`- -------------------- -------- ----------- -----------------------------------------------------------------------------------------------------------------------------•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 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 "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 --- ---- A Title= --- --------- ------ ---------------------------- ------ -------- I (if othe an owner) ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY �I ..... ---------------------- ---------- -- DATE BUILDING PERMIT ISSUED ---------------------------------- - DATE - ADDITIONAL COMMENTS ---------------------------------------- ------------- --. - - i �I� - f --------------------------------------------- ------ - ------ --- ----------- ------ - ------------------------------------------------- ------------------------------------------------------------------------------ -- ---- ------ - v_: ------------ ---9 i -------- -- --- -- - - - - -- - ------------------------ ---- ------------ Final Inspection by: _ - �..... ----- --------------------- --_ ------..Date -------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.