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ria FOIA OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------- {Complete in Triplicate) Permit No. - 3�1 71 ----------- -- _ it . Date Issued _____--------------- Application __ _____ ___ ___._________________________________�f--l_`1This Permit Expires 7 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 is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOBADDRESS/LOCATION - ----- ---- -----------------------CENSUS TRACT ----------------•--•---- Owner's Name ' �0- - - -- ---- ---------- --------------------------- = Phon -�. � Address /.S~r. T�' _. City ----------- Contractor's Nam �_4.�•_ t��' rf, - _ _ _-_ ------ ------- License # - -------- �- ----- Phone9___ - -- Installation will serve. Residence ❑ Apartment House❑ Commercial ❑Trailer Court El p " Motel ❑Other ------ ------------------------------------- Number of living units:____(______ Number. of bedrooms ____Garbage Grinder --------- Lot_Size_Z$�S<--/SlQ_________________ Water Supply: Public System and name ---- ------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam,:0 t Hardpan [] Adobe ❑ Fill Mat al If yes, type ---------------------------- (Pl'ot: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;[ ] Size------------------------------------------------ Liquid Depth -------------------------- Capacity -------------------- ----Capacity ------i------------- Type -------------------- Material---------------------- No. Compartments --------------- Distance ----- ---Distance to nearest: Well ------------------------------------Foundation ____________________ Prop. Line ---------- ------------ LEACHING _________d:__ _____-LEACHING LINE [ j No. of Lines ------------------------ Length of each line---------------------------- Total Length -------------------- ....... r 'D' Box ------- _._ Type Filter Material --------------------Depth Filter Material---*------------------........................ fl Distance to nearest: Well ________________________ Foundation ------------------------ Property Line. -----------___...... SEEPAGE PIT [ ] Depth ____________________ Diameter _______________. Number =._____.____._ ----- Rock Filled ''Yes ❑ No Q Water Table Depth ------------------------------------------------Rock Size ------------------------- Distance ------------------:---Distance to nearest: Well ----------------------------------------Foundation ---------------:-___ Prop. Line -------------- ....... REPAIR./ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------.____________________} j[Septic Tank (Specify Requirements[ --------- ---------------------------- --- ID -iSposal Field (Specify Requirements) _ , � 4r--�---- --- . _..3� X _ - ____ter______ -------------------------------- _________________________ _______________ ---_._____ ___-____________ _______________________________ __ _ (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 SonJoaquin Local Health District. Home owner or licen- sed agents signature certifies the following: 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." s Signe --------- _ Ownbr €I - ------------------------------------------------------------------ By ------- Title ----------------------------- If - ------------------------------------- [ other than owner) e ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE _._ --------------._------------------ BUILDING PERMIT ISSUED ---�------ ------------------------------------------------- ---------------------------DATE ------------------------------------------- - AbDITIONAL COMMENTS ------------ ---- --- --- -- ------------------------------------------ -- ----------------' --- ---------- -r --------------------------------------------- - ------------------------------------------------------------ Fi'nal�Inspection by- -------- - ---------- ---------------------------------------------------------------------._Date ---fy f!�2,_-F l f i N JOAQUIN LOCAL HEALTH DISTRICT E.,H. 9 1-'66 Rev. 5M f