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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------ u d ....................... ............ Permit No. (Complete in Triplicate) .................................._.........._ ...__.. This Permit Expires f Year from Date Issued Date IssuedfU :_ f 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION 71 10 ...CENSUS TRACT .......__............... � . I Owner's Name - ---- ----------. - -- --...� .Phone 7�4�� Address .. �.. ,.....City .. yrs .......................... ...... ....`.....C..... Contractor's Name .. License # ........................ Phone . .. .. .... .......... installation will serve: Residence J4 Apartment House 0 Commercial❑Trailer Court 0 Motel ❑Other--------�--�•--•.. ........................... __ , Number of living units:-... . Number of bedrooms �CJ_.___Garbage Grinder Lot Size ... ..�R....i/.5..�IwG!/.............. Water Supply: Public System and name --------------- ................................ r.lefl _ w-(erl :.....Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam o Clay Loam Hardpan❑ Adobe Fill Material ............ If yes,type............... 4........... (Plot plan, showing size of lot, location of systemin relation to wells, buildings, etc. must be placed on reverse side.) k NEW INSTALLATION: (No septic tank or seepage pit permitted 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 ...................... Prop. Line ......................V1 LEACHING LINE j ] No. of Lines ........................ Length of each line............................ Total Length ............................ 'D' Box . Type Filter Material {� ...--;n ......-..-. ...�...............De Depth .Filter Material _......-.._...------•--.........=-•---• , Distance to nearest: Well -------------- -------- Foundation ................ ....... Property Line ....................... SEEPAGE PIT { ] Depth ..................... Diameter ................ Number ---------------------------- Rock Filled Yes ❑ No [IL-- Water Table Depth ........................................._......Rock Size -------------------------------- D r Distance to nearest: Well ..............Foundation .................... Prop. Line ..................... REPAIR/ADDITION(Prev. Sanitation Permit=# ..... _... � .) • f Date o A Septic Tank (Specify Requirements) tS.. � p - ..................................... y 'r Disposal Fieldpecify R quirements) -- --��;$B f .:...... ................ p _ v 6_5 -r-------- - ._7,- �f7..-,--•------ .. _ - ---- r ................................... .... l (Draw xis= g and equired addition on reverse side) 1 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 focal Health:District. Homo 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 be Lome subject ter man's Compen tion laws of California." -- Signed - � 1 1 --- - t1 RP-1-VA _q.� ,. ..----- Title 1 (If other than owner) OR DEPARTMENY USE ONLY I APPLICATION ACCEPTED BY _.._-. ------- DATE _ - BUILDING PERMIT ISSUED ................... .................................... ..................................•----DATE -------------_-----____ ADDITIONALCOMMENTS . ..........................:.........................................................•-------------- 4 -----------------------•-------..._------•----•----•- --------------------•---------------_--••-_.--------------------_ ....................... --------------------------------- ----- ----------------------------------------- ------ - - .............................................................._ .-` Final Inspection by." . -- . •............. ....•----....----------.....Date ..... .. "-- -• •- { EH 13 Zit 1-68 Rev 5HSAN J QUIN LOCAL HEALTH DISTRICT 8/7h 3M r ��