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FOR OFFICE USE: PPLICATION FOR SANITATION PE471 T /�//� ,7 5-F/ (Complete in Triplicate) Permit No. - ---- ------------------------ ------------ --------------- This Permit Expires 1 Year From Date Issued Date Issued =.� D Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein r described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: / G �I 'I . JOB ADDRESS/LOCATI N -fs�--- -------------0 --------- -- --- ---�--- CENSUS TRACT --------------------- Owner's Name - ---- ---------------- ---------------- -- Phone t - - S Address - 6 /, r--- J --- ------------ city f ' Contractor's-Name ----- - ----- .�`f`------►--- --=--=-------License # --ef-_ -- Phone --------------•------._..--- Installation'will serve: Residence $ Apartment House ❑ Commercial .❑Trailer Court ',❑ Motel ❑ Other -------------------------------------------- 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'0 Silt O Gay ❑ Peat❑ Sandy Loam;] Clay Loam ❑ Hardpan ❑ Adobe'D Fill Material ------------ If yes,type ----------------_----------- Mot`plan, ___-___._{Pot`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 11 SEPTIC TANK'I ] Size---------------------------------- Liquid Depth ----------------------------- Capacity ----- ----- Capacity --- ----- ------ --- Type ------ �-._`Material---------------------- No. Compartments ----------------- Distance to nearest. Well -------------------- Foundation ---------------------- Prop. Line ---------._..:-_....-- LEACHING LINE [ ] No. of Lines _ ':'____ _ ___________ Length of each 'Eine--------------------- ------ Total Length ----------------------------- ------------- _-__-_____.___==------ Type Filter Material --------------- ----Depth Filter Material --------_--------_..---------------------.- Distance to nearest: Well'_:--____�___ __ Foundatiari __._.___'_______________ Property Line- -___-____-_..__-:.___ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes 'E] No 0 Water Table Depth ---'----------------------- --------------------------------------- Size ------------------------•------- , Distance to nearest: Well ---------------------------------- -----Foundation -------------------- Prop. Line ----------_---------- REPAIR/ADDITION(Prev. Sanitation Permit# ------:.------- -------------- Date __________________________________) SepticTank (Specify Requirements) --------------------------------------- ------------------------------------------------------------•------t---- ---------------------•- Disposal Field (Specify Requirements) -/+---------•------ --------•-.`--^----J�---------�-----------------�------------------------------------------------•--------------- ------------- ------------------ - ______-__ - -------- - --O_______________S_____ _________I_______-_______-__•__•__ S ____-=Yti�________ __ "G __-_ --- ----- - -:�� -------- ------�'---X �� ` r`---- ` ` (Draw existing and required ddition 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-Districtr•Home-owner-•ot-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 ------ _.. - (lf other than owner) 644 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - t ----=------------------------- ----------------- DATE ._L -----`-�-��----------------------- BUILDING PERMIT ISSUED ------------------------- -------DATE -- ------------------------------------- ADDITIONALCOMMENTS ------------------------------------ ----------------------------------------------------------------------- --- -----------------=----------------------- --- ------------------------------- R _ _ -------------------------------------------------- ------:__--------------------- �- �-:_�:: ----- - - --- -- - - - - - - - Final Inspection by: f ------------------------------------------ -----------------------------.Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M