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z FOR OFFICE USE: ^°i •i APPLICATION�FOR SANITATION PERMIT --------------- -------------- ��. �'� .� y Permit No: 71-9d (Complete in Triplicate) Date Issued ___ ________ ____ ---------------------_-------------------_______________ This Permit Expires i Year From Date Issued �- _ Application is hereby made to the San Joaquin Loc I,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: JOB ADDRESS/LOCATI N - -------- �i�_ ----------__ ,_CENSUS TRACT _._______________________ I Owners Name L� ----- �� i� F',. i�� '� ---- --Phone.91 --- Address tY A '��- ----------------:- - _. Ci Contractor's Name _----_. installation will serve: ResidenceXApartment House❑ Commercial ❑Trailer Court.,E M,t , f t }I--------------------------~*____________ yI?, Motel -Other.,•- __- Number of bedrooms _______Garbage Grinder-- Lot Size Number of livingunits:.___ Water Supply: Public Sys m and name,__. _ _`f /f l -t �°,� 1:_>„-__---- __:_____: =Privdte;❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑' Sandy Loam ❑ Cld,y=froam:❑ Hardpan ❑ Adobe Fill Material ------------ yes, type --_------__-___________�-_ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be Olaced on reverse side.) NEW INSTALLATION: (NO septic tank or seepage pit permitted if public sewer is available within 00 feet,) PACKAGE TREATMENT []'] SEPTIC TANK'[ I Size----------------------------/----------------- Liquid,Depth ----------------........ -- 3apacitY -------------------- Type -------------------- Material-------- ----------- No. Compartments ---------_----•••-- Distance to nearest: Well -------____---_---___________-_-_Foundation ___--_____________ Prop. Line`__________________ ___ ".0p LEACHING LINE ['). No. of Lirii's's" -"--____--__--____ 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's❑ A �. s Water Table Depth -------� --------------------------------Rock Size�_- - --__--_-__ # Prop: Line _. _.. ___._ � Distance to nearest: Well________________�"~Foundafiion-^__a_�Z_r�___ _ _ l> _______. I REPAIR./ADDITION(Prev. Sanitation Permit# -------- -------------------------- Date ----------- ----------------------- t SepticTank (Specify Requirements) --------------------------------------------------------------------------- I--------------- ------------ •------------------------ D'; I --.-----------\kk D'spasaI Field (Specify Requirients) _ ,% 0, ---- - ,��` ________ -------------------------------- ------------------------------------_:-:.-.-.._. - -.- -------- -------------------------------------------------------- -------------: -------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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: "1 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 Cdlifornia.” f Signed ----- ------------------------ --- ----------- Owner r BY ----------------------- --'----------------- Title -- ------ �'-r (If o#her # owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ----- ------------------------------------------------ DATE --- ---:;? BUILDING PERMIT ISSUED ------------------------------------------------------------------------------------------=--------------DATE ------------- -.,/-------------------- --- ADDITIONAL COMMENTS --------------- ---------------------------------- ------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------- ----------------------- ---------------------------------------------------------------------------------------------------- ---------------------------- ------- -- ----- ----------- ----- -- --- - ----------- --------------------- - -- -- ---- ---- -- ---- ----- -- --- --------- Final Ins ection b Date ----- - p Y- -l` ---7�-•------ SAN JOAQUIN LOCAL HEALTH DISTRICT 2� 'i Y4 E. H. 9 1-'b8 Rev, 5M i, * ,�„ ,