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1, FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No ..t-. - Date Issued-V17 .6_.71 •-••••..--------••-------- ..................... This Permit Expires 1 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. i This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: 1 JOB ADDRESS/LOCATION.. �1� .'� ' ..:../.._ . .-- . - ------..........CENSUS TRACT........................_....... Owner's Name _ . . . ................................. ....... . ..................... ......... .. .. Phone- G 9 !4 3 ........ IAddress-..... a�"I' 7� ... �------ ..... .. ... ...... .........................City. ........----. --Zip--------------.......:------_. Contractor's Name............ ..... License #.. -G.�3 ��'�..._._..Phone.. /.O/. -------- Installation will serve: Residence �' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other......... -- -- ----- ---------- Number of living units:...,---------Number of bedrooms....aZ. ..Garbage Grinder............Lot Size....... ........ . ..............:............. .... .. I Water Supply: Public System and name-- ----------------- ------------------------------------------- Character -------.-..----- Private Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam {] Hardpan 1. Adobe ❑ Fill Material.. ....If yes, type----------------------------- (Plot 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,) Z PACKAGE TREATMENT11 a I 1 SEPTIC;TAN1< Size ------ -------_------------------- ---.Liquid 'Depth.—-...----- 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................. • i SEEPAGE PIT `E 1' Depth................Diameter......--....--------Number-._--------------------------- Rock Filled Yes ❑ NoN, Water Table Depth.------•------------------- -------.Rock Size---- .. ..... ............. ---- ....... Distance to nearest: Well ....................................Foundation-----......................Prop. Line..--.------ ..........-.-.. t REPAIR/ADDITION (Prev. Sanitation Permit#................................... ...............Date----------------..----------.._.__...---------) Septic Tank (Specify Requirements)- t - ` --------+------------------- - ----- ---------------- ----- -- ---- ----- ------.----------- Peci# � - Requirement5)...:. --DisPosal Field (S - ---- . .. (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 Local Health District, dome owner or licensed agents signature certifies the following: t "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 sub'9,6407 orkman's Ca pensation laws- of California." q_ R Signed-----..... ` t; .--.... ----- Owner l ----------- --------- By_ ---- -•----- -- ------ ---------------- '�" -- -- - --- .. .. . .. . ................ Title_..._._.... '.. -.-- ----- --- - i (If other than owner) F DEPARTMENT USE ONLY oe I . APPLICATION ACCEPTED BY.---- �'' ::. DATE .... .. ... . -- ---- DIVISION OF LAND NUMBER.:. ]' . ._......: DATE -- ------ ADDITIONAL COMMENTS... .. .......... .....::. ------------------------------------------------------------ .... ------------- ) ......... . ------------------ -- -------------- -..-....------ .---- ----- ..-- . -- --------------------------------------- ........ Final Inspection by: ......... -- ...... Date.... f-- ..�,7.- '✓... ..... i EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21 677 REV. 7176 Sen