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FOR OFFICE= USE: APPLICATION FOR SANITATION PERMIT - �0 ------ :eN4 -!-------�-�� - 71 ` }Perm it No. (Complete in Triplicate) '------ - = This Permit Expires 1 Year From Date Issued Date Issued _---------------_------------_----------_------------- JI Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: � y G ---J - OB ADDRESS/LOCATIO -------- ---------- -------- CENSUS TRACT ------ Phone --------- Owner's Name ----- , Address ------ ------------------------------ ----------- -=---------------------------------------------- City --------------------------------------------------------------------------- Contractor's Name - -------- 40 .License # ------------------------ Phone -------------------- ------•-- - --------------- Installation will serve: Residence artment House❑ Commercial ❑Trailer Court ,❑ Motel ❑Other -------------------------------------------- Number of living units:-_. ----- Number of b ---...Garbage Grinder ------------ Lot Size .- - -��'- -------------- --- Water Supply: Public System and name !/ - Private F-] Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adob5K 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,) PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth --_-----------------------i Capacity -------------------- Type -------------------- Material--------------------- No. Compartments ------------ ......... r Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length _____-___-___-_...._-._--- m 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------------------------------- •------- Distance to nearest: Well ________________________ Foundation ________--_--------._____.Property Line ------------------ -----0 SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 , WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line _______-__---- 0 REPAIR/ADDITION(Prev. Sanitation Permit# ZV_3-(_n--------------------------- Date/6- - -9--J _A_(------ /// i C Z�v 0� Septic Tank (Specify Requirements) ---------------------- ---- --- --------------------------- -6, -------------------- --, - ----------------------- - Disposal Field (Specify Requirements) � �' -�___� �-,l--l-e-�--------'---�''�--�-----d-L=`--��--_----- ru---''�� o- u , E�''1 ; ---------- - �- ' f��= r l/ f!4 f1; ` (Draw exi ng and requireddditi non reve se side) 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. Home owner or licen- sed agents signature certifies the following: "I certify tha m the performance of the work for which this permit is issued, I shall not employ any person in such manner as to beco e s.bject to Work an's mpensation laws of California." Signed --- - --- C`14 ---- ----------------------- Owner By ---------- ----------------- -------------- --- ----------------------------------------- Title (If other than owner) AiiTMENT USE ONLY APPLICATION ACCEPTED BY ----- �, �"` DATE _- --`-- -. -------------- - ------------------------------- BUILDING PERMIT ISSUED -- ---- - --- ----- -- -- - -------------- TE -DA ------------------------------ -------------- - ADD TIONAL COMMENTS �' ---- -- ---------- - --- �' �- r Q- 5' c(W- l s ------ ---- �F = G # k ----- f f ------- ----------- Jf �*�fi �14li -W" ie--- -- - If - ---- -r ---------- - ---- - a ►1_� v_u -------- --- --- FinalInspection by: ------------------------- ---------------------------------------------------------------------------------Date -------- ---- -- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M -�