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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: 71_-__Vp/___ . ----------- ------ ----- ----------------------------- (Complete in Triplicate) x - --------- --------------------------------------- ---- pate Issued .'Y:�!;217�71---- This Permit Expires 'I Year From Date Issued -------------- Application is hereby made to the San Joaquin.-Local )=Health District for a permit to construct and install the work herein described. This application.isfmade in compliance with County Ordinance No. 549 and exist' gi Rules- and Regulations: �7 jo ;�1 0 41C ' ST hb *—"__ 1' ---a�.46QkgCENSUS TRACT ---------------------- •- JOB ADDRESS/LOCATION _ - - - - ---- ------------ ----- - Owner's Name - C-'1�'--- ---- �'3°--- - Phone Address . " -------- -------- ------------------- City �� t Contractor's Name ----��-- -- ----- -- ----------- ----_4_ n ----t-------.License # -. r _ P ne ------------------ ----------- Installation will serve: Residen a ['Apartment House❑ Commercial []Trailer Court C] Motel ❑ Other 1 Is ____. Number of living units:------- Number of bedrooms ____-__ Garbage Grinder ___________ Lot.Size _______________________ ___ ___ Water Supply: Public System and name --____-_____ Private ❑ --- ------------------------------------------------------------ ----- - Character of soil to a depth of 3 feet: Sand'[,] Silt ❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ Hardpan ❑ Adobe-❑ Fill Material ------------ If yes, type ------ --------------------- Iv {Plot plan, showing size of lot, location of system in relation to wells, buildings, etc_ must be placed on reverse side.} a NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------- ---------- Liquid Depth --------------------,----- Z_ 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 ❑ Water Table Depth -------------------- ------Rock Size -------------------------------- Distance to nearest: Well --------------------------------------- Foundation ----- -------•--•-- -------------- Prop. Line ________. [ REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date --------- ------------------- ---- Septic Tank (Specify -Requirements) ------------------- --------------------------=----------------------------------•--------------------------. ------------- Disposal Field (Specify Requirements) . a -�' 4 �---------- -------- -------------- --- .� / ----/-ply� ------- - - - - - - - ------�-------------------- - ----� ------ 11,-- ------- - --- ----- -- - --------------------- ---------- ------------------- --------------- -- --------------------------- -I------------------------------------------------------------------------------------------------------------------------------------------------ (Draw existing and required addition on reverse side) 1 hereby certify that l 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 Wealth 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 lawsofCalifornia." 2 Signed - ---------------------- ------------- - Owner BY (If other than owner) FOR DEPARTMENT USE ONLY 7 AFPUCATI�N ACCEP�� B c..c- -------------------------------- DATE sf [-I -- - ----------- - BUILDING PERMIT ISSUED ---------------------- --------------------------------- DATE ADDITIONAL COMMENTS ------------------ ----------- -------=---- --------------------- --------------- _ __ ------------- -------Date - ------------------------Final - - Ins action b - -- �----- =' - ----------- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.