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FOR OFFICE USE: 611 APPLICATION FOR SANITATION PERMIT /n-_-1 p -� _ '7 (Complete in Triplicate) Permit No.(�`1 _______________________________.________-_-____________ This Permit Expires 1 Year From Date issued Date Issued -_.._______- 91 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 complia ce with County Ordinance No. 3.49 and existing Rules and Regulations: JOB ADDRESS/LOCATION .-/-7-Z./. ------f, e-�*� /-----------"------------ ---CENSUS TRACT --- Owner's Name -------------------------------------------------- --- -------------Phone.-175W-- 2�1- Addressy ---F -------------- City ----------------------------------._..... Contractor's Name _[" w ��_-- ,-------.License # n2,5-!Y173--- Phone __3 Installation will serve: Residence XApartment House°❑ Commercial:❑Trailer Court ;❑ Motel f-1 Other -- ---- -------- ---- ------- Number of living units:______ Number to4drs _____Garbage Grinder ___-__--__-- Lot Size d_fi?C__�a_ __�_.___.___./ �Water Supply: Public System and name �:1�_��_{-------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 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.) v NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) J PACKAGE TREATMENT [ I SEPTIC TANK f ] 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 [ ] Depth ____________________ Diameter ----- "_______ Number ---------------------------- Rock Filled Yes '❑ No 0 Water Table Depth ---------------------------------------=--------Rock Size --------------------•----------- Distarice to nearest: Well ______________________________________Foundation __.______-_ ------ Prop. Line ........ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ______------------------------_.--] SepticTank (Specify Requirements) ------------------ =--------------------------------i-------------------------------------------------------------------------------------- R Disposal Field (Specify Requirements) __ ___ ------------------------------ -------- ---- - -------- --- ------------------------- .- - ------- ----- ----- ----------------------------- , . . -------------------------------- ----- ------------------------------------------------------------------ ---------- - - -- - - - - - -- (Dra existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that' the work will be done in accordance with San Joaquin t 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 bec a subject to ork s Compens ;1_aws of California." /� y ti Signed _ -; --- - ---- ---- ---------- Owner By --------------------------- c ----- Title ----------------------------- r (If other than o er) )DXrt PARTMENT USE ONLY i APPLICATION ACCEPTED BY --------- --------------- DATE -------/�__" �'-��------------- BUILDING PERMIT ISSUED ----------- "' - -=-------------DATE -----------------------------•-------- ADDITIONAL COMMENTS --------- --- ----- '``_- - ---------- ---- ---��-- � - -------- - ----� -- r ------------ - - Final Inspection by: ----------------- - ------ ---- -----------------------------------------------------------.Date --- N -N LOCAL HEALTH DISTRICT �� { E. H. 9 1-'b8 Rev. 54M .• - F '• .: . -