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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------------------- ------ {Complete in Triplicate] Permit No: ._71-_S7 fc --------------- This Permit Expires I Year From Date Issued Date Issued _�jvzl Application is hereby made to tH-e San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: co�� JOB ADDRESS/LOC TION Z -- -- - - _- � _CENSUS TRACT -------------------------- Owner's Name .-- --- .- I� _ Phone ------------------------ Address -----. a ---- ---- --• -- ----- --------. City ------ -- ---- --- -------------------------------------------•------ �� i Contractor's Name __-- -- �Yct -____-____--.License # �- -- Phone ............ ................ Installation will serve: Residence 4Apartment House-E] Commercial:❑Trailer Court 'E] Motel ❑ Other ----------------------=--------------------- yri Number of living units:------- Number of bedrooms. -3_ __:__Garbage Grinder ----_--___- Lot Size _ ar.-zt sx�------------------ n .. Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑- .Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Gay Loam-0 11 Hardpan V Adobe-❑ Fill Material ------------ If yes, type ---------------------------- 8 (Plot plan, showing size of lot, Iaocation of system in relation to wells, buildings, etc. must be placed on reverse side.) � I NEW INSTALLATION: lNo 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 ----------- O! Distanced to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ________________._._._ LEACHING LINE [i� No. of Lines ---------/------------- Length of each line-------- r�----------- Tota! Length .-_7S_--_-___-----_--_ 'D' Box -°----------- Type Filter Material -__g_A---------Depth Filter Material ---------------------------------_-----...-- 0 Distancetonearest: Well ________________________ Foundation ---___-_______--___ Property Line .-__-_-_.-.-.._.__--.._- SEEPAGE PIT [ ] Depth __°___________ _____ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- �� r Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------------.---.._. REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _-_______________________________) SepticTank (Specify Requirements) -------------------------------¢---------------------------------------------------------------------- ------------------------------------- Disposal Field {Specify Requirements) --- f(--- D___ F ----�m ----- -----------1----------------------- ----------- ------- " - ------'------------------- ii (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: "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 Workman's Compensation laws of California." Signed 11 ------------ ------ Owner �i By ---- ------------------------ ----- ' "`.-`' Title [If other than owner] li FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ - _ - _ _ _ _ _ ----------------------------------------------- -------------------- DATE -6_��`- L------------------- -------- BUILDING PERMIT ISSUED --------- -------------- ----------------------------------------------------------------=--------------DATE - ------------------ ----------------- ADDITIONALCOMMENTS ----------'------------------------------------------------------------------------------------------------------------- ------------------------------------- --------------------------------- ------------------------------------------------------------------------------------------------------------------------------ - - - --- ------- - -- ------------------- -------- -------- ----------------------------------------------------------------------------------------------------- - - - --------- .� _ ---------------------------------------- ------------------------------------- - -------- Final Inspection by: ------------------------------------------------------------------- ---- -Date W -71----- - - ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.