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FOR OFFICE USE: - APPLICATION FOR SANITATION PERMIT l (Complete in Triplicate) Permit No: _ '------------------------------------ _ .This Permit Expires I 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 vyith County dinance No. 549 and existing Rules and Regulations: // �J1 JOB ADDRESS/LO ATION .---- ' --_ - , ri� -_ CENSUS TRACT --------------•-- ___-- Owner's Nam --------------- --- ----- = .._. Pho Address /S4_!, ------------------ City " - ----------------•-- Contractor's Name ----------------- - - ------------ ----------License # ------- ----------------- Phone ------------•--- Installation will serve: ResidencegApartment House-[] Commercial;❑Trailer Court ❑ Motel ❑Other !` Number of living units:-----/_- Number of bedrooms "_-!___-.Garbage Grinder ------------ Lot Size _______________________ i Water Supply. Public System and name -------------------------- --•-•----------Private ❑ 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 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 --- ....... LINE [ ] No. of Lines ------------------------ Length of each line-------- ------------------- Total Length -----------_ .•----------- 'D' - -'D' Box ------------ Type Filter Material ____________________Depth Filter Material -------------------------------------- Distance _-________. _Distance to nearest: Well ------------------------ Foundation ------------------ ----- Property Line: -----.--------.....:. -- 'k SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock filled Yes ❑ No 0 Water Table Depth ------------------------------------------------Rock Size ------------------ Distance to nearest: Well ______"___._____________________ -----_Foundation -------------------- Prop. Line ............... REPAIR./ADDITION(Prev. Sanitation Permit# --------._ ____ " _--______ Date ..... -_} Septic Tank (Specify Requirements) -- ' _ ----- ---/ — ' Disposal Field (Specify Requirements) �'�- ---------------------------------- ----------------- ________ ____ raw existing and required addition on reverse side) t 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 inthe erformance of the work for whi h this permit is issued, I shall not employ any person in such manner as to beco a subje o Workm s Compensation I s of California." Signe c' -- - - Owner By -------------------------------------- ------ --- ------------- ----------------- Title -------------------------- - (If other than owner) FOR DEP ENT USE ONLY APPLICATION ACCEPTED BY . -- DATE BUILDING PERMIT ISSUED " ---------•------ ADDITIONAL CCMAAAENTS --- ---------------- --- ------ . -' I�------------------ a t------------- �P --- ---- ---- t o I�'------ /!1u �tt��-`S c'�- f t Final Inspection by: - Date ----- JQAQUliE LOCAL HEALTH DISTRICT �� r acre, �. E. H. 9 1-'68 Rev. 5M