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FOR OFFICE USE: � vg= — All_ APPLICATION FOR SANITATION PERMIT ----------- Permit No. ------- / p P (Complete in Triplicate) y-� j°-------------- (� 1 _______________ _____----------____--_______ This Permit Expires 1 Year From Date Issued Date Issued -_r-'�T_�.$. : i 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 O inane/ N . 549 and existing Rules and Regulations: --- - � JOB ADDRESS/LOCATI ---------t_-_-- -- -- �� ----------------------------CENSUS TRACT _-.- -I --_-----_---- f Owner's Name ------ <� -------------------=------- --Poe --------- ----------------- ----- -------- Address --- ---- --- . City ---- 0_�_ �-- / Contractor's Name _-__ ________________License # o Phone _ ____ J Installation will serve: Residence artment House-E] Commercial :❑Trailer Court ':❑ Motel ❑ Other --------------------------------------------- Number ofliving units:_._____.__ Number of bedrooms ------------Garbage Grinder ef�... Lot Size _- - / _____________ WaterSupp[y: Public System and name --------------------------------- -----------------------------------------------------------------------------Private i Character of soil to a depth of 3 feet: Sand'❑ Silt]] Clay ❑ Peat D Sandy Loam ❑ Clay Loam '?,, oam . Hardpan ❑ Adobe X Fill Material If yes,type ---------------------------- [Plot ______________________ ____{Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) \ NEW INSTALLATION: JNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) 4 . PACKAGE TREATMENT [ } SEPTIC TANK[ ] Size--------------------------------------------- -- Liquid Depth --------------------------- --------------------- ------------------------- ------------------- Type ------------------ Material---------------------- No. Compartments -------------------- Distance ---------Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ------------- -------- LEACHING 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 _______________-__-_-___ J SEEPAGE PIT [ ] Depth Diameter ________________ Number ---------------------- Rock Filled Yes ❑ No 0 j s Water Table Depth ------------------------------- ----------------Rock Size ---------------- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ________-_- _ ----__-- ' REPAIR/ADDITION(Prev.`Sanitation Permit# -------------------------------------------- Date _______-___----------------_-_) I Septic Tank (Specify Requirements) ------------------ ---------� • ----------------------- / Disposal Field (Specify'Reqs irements) --------- �2� `1-�- ---------� 1------------..� ;1- -- --------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------- (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 i 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 r as to become subject to Workman's Compensation laws of California." i Signed ----------------------- _ Owner -- -- -- ----------------- ----------------------------- By ------------------------------- - - - --- ----- - `" Title - --------------------------------------------- (If ot than owner) ? EPARTMENT USE ONLY APPLICATION ACCEPTED BY --.- - N --------------------------------------------------------- DATE ------------------- BUILDING PERMIT ISSUED ------------ -- -- ----------------------- -------------------- DATE ------------------------------------------- 't ADDITIONAL COMMENTS __. _- - -___ + �-- t--- ---�-------- ----- ------ - -- -- - } -------- - - ---_------- Final Inspection b ------------------------------------ ---------------------------------------Date ---- N JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M. 1