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FOS oFFiC USE: APPLICATION FOR SANITATION PERMIT �4 ---- _� �_,_. _. __ _ -71_io q ----- ----,�.-------- Permrt-Ao. (Complete in Triplicate) Date Issued _ ------ ----------- _�-_�_____--------_------ This Permit Expires 1 Year From Date Issued . 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 Wmade in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION _.-_. 71t_� - ----------CENSUS TRACT -------------- ----- f /-.1_._�lef, , --_-._L - f I Owner's Name -------- _ Phones _ , ' ,,��gg ---------- - - - --' - - - - ------- -°--- Address v` - - ---------------- ------ - City - ` Contractor's Name ___ ___.-_. -�n _d¢. ----- - -.-._-._-...License# � _--.- Phone --- Installation will serve: Residence gApartment House'❑ Commercial []Trailer Court .:, Motel ❑Other ------------------------------------ ----- Number of living units:----I-_--`_ Number of bedrooms .___`_.Garbage Grinder ____ ___.._ Lot Size ._.-._.fa.0_. -�'.................. Water Supply: Public System and name -------- ---- ------ --Private ❑ Character of soil to a depth of 3 feet: Sand❑ 'Silt❑ Clay ❑ Peat❑ Sandy Loam X Clay Loam ❑ a Hardpan I p, ❑ Adobe '❑ Fill Material ------------ If yes, type ---------------------------- f (Plot plan, showing size of lot, location-of.system-in elation to wells, buildings, etc. must be placed on reverse side.) i NEW INSTALLATION: (No septic tank&or seepage pitYpermitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ) SEPTIC`TANK: ' " `! Size-------- - -__ Liquid. Depth �._`.._-- -- - -------------------------- - ------------- Capacity - - __-- Type - Material --_. No.� Compartments ......... Distance to nearest:. Well ______-_--_____________________Foundation _--1 ------------- Prop. Line --__---- _.._ LEACHING LINE "6Q No. of Lines -_-__ -_.._ Length•of each linen---_--70.'-.�__ g t ` Total Len th _. /__U______________ � z �� 'D' Box -----�""Type Filter Material f - ------Depth Filter- Material ----/&----------------------_____---_ —��--- ��p ------- Property Line --. -------------- Distance to nearest: Well -.._,-�.`.-.� .� Foundation SEEPAGE PIT [ ] Depth _-____-__-._--_.._ Diameter ^ -__ -_-_,._ Number --------------- ----- Rock Filled Yes ❑ No 0 i Water Table Depth ------------------------------------------------Rock Size --- -------------------------- Distance to nearest: Well ----------------------------------------Foundation _._.--------------- Prop. Line ---------------------- R EPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------- Septic ._-.---- _..._-________-} SepticTank (Specify Requirements)"---------------------------------------------------- --- ---------- -----------• ----.-------------- --I--------------------------- I DisposalField (Specify Requirements) ----------------- ------------------------------------------------------- ------------------------------------------------------------ ------- ) ----------------_------ ------------------ -------------------------------------- ------------------------------------------------- -'--------------------------------------------------------------------------------------- (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 LocaltHealth District. Home owner or licen- sed agents signature certifies the following: r "I certify that in the performance of the work for which this permit is issued;I`shall not employ any person, in such manner s .as to become subject to Workman's Compensation laws of California." k Signed __ Owner By ------ --- --- Title" ,- _'C�' "'r -- ------- - --- (If other t n owner) f FOR EP RTMENT USE ONLY APPLICATION ACCEPTED BYC --_____ _ � �__ _.._.: DATE11-Aa .. �__.--_..____...._ - ---------------------------------------- BUILDINGPERMIT ISSUED ------- ----------------------- ------------------------------------------------------ -------------DATE ------------------------------------------- ADDITIONALCOMMENTS ---------------------------------------------------------------------------------•-------------------------------------------------------------------- ----------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- --------------------------------- --------------------------------------------- ----- ----------- -- --- --- - -- /� _ _ _ i Final Inspection by -------- -- ----- - -------------------Date �''-- ------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ""