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' FOR OFFICE USE: � ' APPLICATION FOR SANITATION PERMITS& WW ----------- lComplete in Triplicate} 7� I__._ _.�.. .. ..�__... ....._...._.-..-. � ................ .: . _..... _ __� , r . f 76 p � — Y 7 I� Permit No ..................... This Permit Expires 1 Year From Date lssued'76� date Issued .. '.a.7—:..-- 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 c mpliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCAT#ON ... ° .. . . ....... ......................CENSUS TRACT .......................... Owner's Name Phone ......... �...... ........................ ... ............ Address . City ................................................................... •.. Contractor's Name ....License ,# ................... . Phone installation will serve: Residence❑Apartment House 0 Commercial ❑Trailer Court 0 Motel ❑Other--------------- Number of living units:...-�--.--- Number of bedrooms 9—____Garbage Grinder .Q..4.... Lot Size ....1. ?'.+:........................ Water Supply: Public System and name -----------•.................-.................................................................................Private J' Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan 0 Adobe.0 Fill Material ..._ ....... If yes,type ............... ............ � S {Plot plan, showing size of lot, location of system In relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet) PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size.................. ....... Liquid Depth .......................... Capacity __------------ --- Type ----•----------- Material...................... No. Compartments .................... Distance to nearest: Well ------------------------------------Foundation Prop. Line -.....................Lr [ ] g .... Total Length LEACHING LINE No. of Lines ---------------•-- --.-. Length of each line..-----•-.------_---- -- ............................ a 'D' Box ..-....._:.. Type Filter Material ................:...Depth Filter Material ............................................ Distance to nearest: Well ........................ Foundation -....................--- Property Line ........................� SEEPAGE PIT [ 1 Depth _-------------- - Diameter ---------------. Number ............................. Rock Filled Yes ❑ No (']a Water Table Depth ------------------------------------------------Rock Size ................................ Distance to nearest: Well ------------ .------foundation -----r......:....... Prop. Line -___..--...... ....... REPAIR/ADDITION{.Prev. Sanitation Permit# ..... --------------------- ------------ Date ..._. ...................... Septic Tank (Specify Requirements)........... • Dis os I Field (Specify Require encs) ..................................... .•- •-• (Draw existing and requiredad itio rde} I hereby certify that I have prepared this application and that the work will. be clone 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 ------------------------------------------------------------------------------------------------- Owner � By - ----- Title ....... ...... ........_.. (If other than.owner) FOR DEPARTMENT usE ONLY APPLICATION ACCEPTED BY DATE . .;. ... �...... .. -----•---- BLIiLDlNG PERMIT ISSUED - ------------------------------------------------ ------ ------- ..............DATE ._.. . -----••-- ...... ...... ADDITIONAL COMMENTS .... - - ----•--------------- `- - _ / -------- 111.1 final Inspection b Date lr' - '/) i p y: -.: . .... -. -�- ...f... .................. .... 4 EH 13 24 1-681 Rev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M �