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FOR OFFICE USE: 'I _------------- ---- - APPLICATION FOR SANITATION PERMIT - � f --- (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 C my Ordinance No. 549 and existing Rules and Regulations: _ = ------------ - ' -- JOB ADDRESS/LOCATIO CENSUS TRACT Owner's Name ----------- ------Phone ------ Address _ - -------- --- ----- --- r 6 ` -- ---- --------------------------- ------ ----------- Contractor's Name --_-- ----------- --------- -----License # � e __ Phone ----------------- - Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court Motel ❑ Other Number of living units.------ Number of bedrooms 6------Garbage Grinder ------------ Lot Size _ ------------------ ---------------- Water --- -------a er upP Y- Public System and name - -------------- --------------Private ""�- Character of soil to a depth of 3 feet: Sand'❑ t❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay,Loam ❑ a Hardpan,- Adobe '❑ Fill Material _______-__"If yes,type ________--._____ g'. (Plot plan, showing size of lot, location of system in relation to welts, buildings, etc. must be placed on reverse side.) it NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ]i� SEPTIC TANK[ ] SizeLiquid Depth _.____________._ ----.----- ��f Capacity ---- ------ ------ -Type -------------------- Material---------------------- No. Compartments ------_ Distance to nearest. Well ------------------------------------Foundation ----------------'------ Prop. Line _---------.--------- LEACHING LINE [ ] No, of Lines ----------------------- Length of each line---------------------------- Total Length Box -------- --- Type Filter Material --------------------Depth Filter Material --------------------------------------------- Distance -----. Distance to nearest: Well ------------------------ Foundation `----------------------- Property Line. ------------------------- SEEPAGE --------------__ --.--SEEPAGE PITDe _pth __--_--_ ____----_ Diameter ________________ Number .__--y________-.____-___ Rock Filled Yes [-INoi❑ [ 1 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) ---------------------- ------- - - -_ __ _v_e_r_se {Draw existing and required additi-o-n--o-n reversseeside) - ..,J I hereby certify that I haves 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 subject to Work an's Compensation laws of California." Signed ---------------------- --------- Owner --- --------------- ---- - BY ---------------------ten - - ----- -- ---t = Title ----- �6�� (l other than owner) � FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .---- --- -------- =. DATE ��- ------------------- -- B ILDING PERMIT ISSUED --------- ----------------------- -------DATE -- --------------- ------------------------ T ONAL COMMENTS __'�_______________ , -------------------- - -------------------- ---- ------------------ -- - D ---- ----------------------------------------------- ' ---------------------- - ----------------------------------- -----Final Inspection by: -- - --- ----- ----------- ------------ --- -------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M w