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r FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ______________________ This Permit Expires 1 Year From Date Issued Date Issued __-----:�a_` '� 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 CouM nce No. 549 and existing Rulexad--RegUlotions: JOB ADDRESS/LOCATiO /f � K__-�-[--__--__CENSUS TRACT -- ------------- Name -------- - o—o------------------------------------ - --------- - Y one ---- -- - - -------- city w Contractor's Name -- . _ ___ icense #��. _-__ Phone _______________ Installation will serve: Reside ce Apartment House,[] Commercial ❑Trailer Court i[] Motel ❑Other ---------------------- - Number of living units ----- Number of bedrooms ____Garbage Grinder ------------ Lot Size —_-__.— Water Supply: Public System and name ___________________ _ ------------------------------------------------Private ®� Character of soil to a depth of 3 feet: Sand'❑ Silt EJ Clay [7) Peat❑ Sandy Loam ,F] Clay Loam F-1Hardpan 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 ---_--------------------. Capacity _ --------- Type -------------------- Material---------------------- No. Compartments - Distance to nearest: Well -------------- ---------------------Foundation ---------------------- Prop. Line ----------------- 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 ------------ ----------- SEEPAGE PIT [ j Depth -------------------- Diameter ---------------- Number ---------_ ----------------- Rock Filled Yes ❑ No C Water Table Depth ------------------------------------ -----------Rock Size Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ................--- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date Septic Tank (Specify Requirements) -----------------_.--- ___-__._ -- ------ ------------------------- --••----- ---- Disposal Field (Specif Re uirements) ____-�f--� _ ___ ✓ - - ------ (� ---- - -------------- ------- (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: "l certif t in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to be o subject to Workman's Compensation laws of California.,, Signed Owner ---- - --------- - ------ --------------------------------------- By --- ��rt,-of r -- ------- ---- -------- ---------------------- -Title eal other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ._ _-__._ ----------------------------- -. DATE BUILDING PERMIT ISSUED ....... -- -- ---------- ----- - ---------------DATE ----------- ------------------------------ --------- -`-------- ------------- ADDITIONAL COMMENTS _._____________ ----------------------- ------------------------------------ -- ----------- F --------------------------------------------------------------- 11 Final Inspection by: - ---------- d - --------------------------- ---------------------- ----------------Date -` SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M