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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. -71-711-f.._7 (Complete in Triplicate) -41 Date Issued Date Issued ------------------------------------------ - This Permit Expires 1 Year From 1 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: ` `C.' -- :'---CENSUS TRACT ----'-_---------- -_-�--. - -- ---- JOB ADDRESS/LOCATION ---------Phone �-3--- ---------- Owner's Name ---- . Address ----1-�--=- - ---------- - ---- ---_------- --------- Ci ------------------------------ --------- Phone --------- ---- Contractor=s + f Installation will serve: Residence�Apartment House❑ Commercial []Trailer Court 0 Motel ❑Ot_her _ 'e _ Jz: 2` - �,, ,� ?C_L o-i�----------•- Number of living units: __.1-_____ Numb6T of�bedrooms, ----------Garbage Gfndir _ Lot Size_,_ : -- -- �_ - ; Water Supply: Public System and name4_c___f__-_-______ _- __ ` ----------------Private ❑ I Character of soil to a depth of 3 feet:4txSad'❑ Silt]] Clay E] Peat E] Sandy, Loam [Ia Clay Loam :❑ I LLv ;1H6rd ani ' Adobe F1 Fill Material ------------ If yes, type ---------------------------- F IPlotlplan, showing size of lot,[location of systeih%"in relation,to'wells, buildings, etc, must be' placed on reverse side.} NEW INSTALLATION: (No septic tankyor seepage pit permitted-if-puhlic' sewer'is available within 200 feet,] � I i PACKAGE TREATMENT [ I SEPTIC TANK![ ] E Size--------------------- ------_----- ------ Liquid Depth -------------------------- 4 Capacity T e -------------------- Material-------------- :---- No. Compartments --_------•------------ p Y ---------------- -- YP , Distance to nearest: Well Foundation ---------------------- Prop. Line --------- ...... J • [ LEACHING LINE [ ] No. of tLines _________ ________ Length of each line_} � ---------- -�-------- Total Length ---------------------------- , - t I D' Box ------I----- Type Filter Material -- -- ----Depth ;'.Filter Materia -----------•----------------••------•••---"- t ► l I.I t� i sDistance to nearest: Well -----I- ------ Foundation ------------------ ---- Property Line ------------------•-• SEEPAGE PIT [ ] Depth --- - ---- _ --__ Rock Filled Yes No ❑ { ' Diameter -Number -- ❑ Water Table? Depth ------------------------------------ --------._Rock Size ----- -------------- Distance to nearest: Well ------- --------------------------------Foundation ----#------------:-- Prop. Line _---------•----•----- REPAIR/ADDITION(Prev. Sanitation Permit# -------------- ----------------------------- Date ------------------------------=-- } P (Specify q ------ ------ ' Se� tic TankRequirements) _____ r-- - 1 Disposal Field (SpecifyRe uirements) r '� - --41;. l-- �-t�-------------- foe -----------I� s�4------------------------------------------ ------ ---------------- i -------------- ------------. - --------------------------- (Draw existing and required addition o_n reverse side) E 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 liven- sed agents signature certifies the following: + "I certify that hi-the-perform ce'of"the wdfli for'w—tiith this permit`is'issued;I sh;dIl"nofi employ-any person in such manner as to become subject to Workman's Compensation lawsrof.-Californiia� 'i le Signed ----- ------------ Owner BY ------------ ---G---- -V - ----- ---t--=--- ------------ Title ---- --- - ---'-- ---'---- ------------ --------'--------- - r (!f other t a owned DEPARTMENT USE ONLY APPLICATION ACCEPTED BY I - ------ ---•------------------------------------------------ DATE - BUILDING PERMIT ISSUED -- -" ----DATE -------------•----------------------------- - -- - -- - ADDITIONAL COMMENTS ---- -=-�---- --- - ---------------------------------- --------------------------- - ----- ----------------------------------------------------- -------��---��------------ -- ---- - -� --_=--------------------------------------------------------_______________________________________ ------------------------------------------- -------- - ------ -- - - --------------------------------------------------------------------------------- Final Inspection by- ------- -- - - ----- z Date ----- ---=�w-- -------------- JOA = JOA IN LOCAL HEALTH DISTRICT ^�} .=E. H. 9 1-'b$ Rev. 5M fVl�/