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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----- Permit No. --------- (Complete in Triplicate] ----------I---------------------------------------------- r � ---------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued -11„1--:511 -71 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: !J ----� ` -------------------------------CENSUS TRACT -------------------------- i 108 ADDRESS/LOCATI - --------- --_-- --------- i Owner's Name - - - ------------------------------ Phone ------------------------- -- ----- ---- Address -----470. City ----------------------------------------------------- V7 a f Contractor's Name - --- ----- --- -.License #lgy Phone - ---------------------------- Installation will serve: Residence eApartment House❑ Commercial :❑Trailer Court I❑ Motel ❑ Other ---------- -- ------------------------------ Number of living units:----- Number of bedrooms -3------Garbage Grinder ------------ Lot Size -----------------_-------------_---_-.__--_ Water Supply: Public System and name ---------------------- -------------------------------------------- --------------------- ----------- ---------Private [� Character of soil to a depth of 3 feet: Sand❑ Sift❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam 2 Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ------------------------------ (Plot ----_- '____--:---.- --(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) j PACKAGE TREATMENT [ I SEPTIC TANK![ ] Size------------------------------------------------ Liquid Depth ------ --------------.----- CapacitYTYPe -------------------- Material---------------------- No. .,Compartments i-------------_--- � Distance 1-to nearest: Well ------------------------------------Foundation ----------'------_---- Prop. Line --:--------------_-_-- LEACHING LINE [ ] No, of LiFnes ------------------------ Length of each line---.------------------ Total Length -_-----_I------.---_-_---_-- 'D' Box -1---------- Type Filter Material --------------------Depth Filter-Material _:_-__-_--_------------`---_--_-__-.-.----- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ---- ---_----__---._-_-- SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number --------------- ---------__ Rock Filled i Yes ❑ No i❑ Water Table Depth ' --------------------------------- --------------Rock Size --------------------------------- Distance - -----------------------------Distance to nearest: Well ----------------------------------------Foundation -------------------- mProp. Line ---.---_.----------.-- � r REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date-----------------------------------1 Septic Tank (Specify Requirements) ------------- r Disposal Field (Specify Requi ements) ----------- -------------------------- ----------------------- ----------------------------------------------------- ----- - -------- -------------- --------------------- �r��-`----- -------------------- v --x-----S-- t '-� --- ------ C--- - ---- -- �,-n�_ d - �'�`-------------------- -- -------------------------------------------- D wexisire ad tion 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. Home owner or licen- sed agents signature certifies the following: "['certify that in the performance'of the work for which this permit is issued,,► shall not employ any,person.in,such manner as to become subject to Workman'spensation laws of California." ' Signed -- ------- -------------- -- C� Owner -- ( Title : ------------------------------------ -"---- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION.,ACCEPTED B ---- ----------DATE.--�Z--_Z`------- .--------- BUILDING PERMIT ISSUED --------------- ----------------------------------------- ------- ----------------------- --------DATE ------------- ----------------------------- ADDITIObIAL COMMENTS ------------ � - --------------- ------- - F ------------------------- ---- - F - -------- ---- - .----?.-�- --- ------------------ -------------f - - -----`----------------------------------- - DateFinal !ns ection by- -----s ----- SAN - ---- --- ----- JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.