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FOR OFFICE USE: ------------- �� APPLICATION FOR SANITATION PERMIT Permit No. .-7.3`i DFq (Complete in Triplicate) ------------------------- ------- ----_- This Permit Expires 1 Year From Date Issued Date Issued -10�77-9�73. 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: p� c �� JOB ADDRESS/LO TION .--. '� �( J------- -- �-W R()C�_t_- . --------- ------- ----- -------CENSUS TRACT -, - Owner's Name � � ----- ---------- -- -----------------Phone�i�- - -- ------- ------- AddAddress .- +��/�Q Cit /��4Y-------- ------------- ress - --- -- ----- - - --------- - - --- ��JY---,------------ - Y - p.-� Contractor's Name ---� �-----�� rZ--Jr-- 1--�` e-------=----------License # ---- ------ - -------- Phone F03----- Installation will serve: Residence t2zApartment House❑ Commercial ❑Trailer Court ',❑ Motel ❑ Other ---- ------------------------------------- Number of living units:--- ------ Number of bedrooms ------------Garbage Grinder ----------- Lot Size - --------- Water Supply: Public System and name -------------------------------------------------- -------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'W Silt❑ . ,Clay-E] .Peat ❑ Sandy,Loam ❑ Clay Loam:❑ Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ------------------_--_---- I (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 [ I SEPTIC TANK f ] Size/ine ------------- --------------- - ----- Liquid Depth --------------------------` f Capacity ----------- --- Type ----------------- ateri ----------------- --- No. Compartments -------------------•--� Distance to nearest: Well ------------------ ------ ----Foundat' n ---------------------- Prop. Line ----------_----------- LenTotal Length -----------•---------------- - LEACHING LINE [ ] No, of Lines -_''-------------'----- Length oline__----- ---____-----.--_ __ 'D' Box ------------ Type Filter Material -- -----------D th Filter Material ----------------------- -------------------- Distance to nearest: Well --------------------- unda ion -----.------------_---- Property Line -.-----------_----.----. ` SEEPAGE PIT [ ] Depth -------------------- Diameter -------- -- u . er -------------------_------- Rock Filled Yes ❑ No ❑ ^Water 'Table Depth �' = - ---- - ---------Rock Size ------------------------------------------------- - Distance to nearest: Well ---------- ----------- -----------Foundation ____-_------------- Prop. Line -----.....-----------_REPAIR/ADDITION(Prey. Sanitation Permit# -.-----.------ ----•-------/ -------- Date ----_-----------------------------) Septic Tank (Specify Requirements) ------------------------- ------------- -------------------------------y-------- ---------------------------_�-------------------------- Disposal Fi d (Specify R quirements) -------------------------------------------- -- -- -- ------------------------ - -- ----- � zp-e-- --- ----� � ' � - - - - -------------------------------- - ( raw existi g an 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. Home owner or licen- sed agents signature certifies the Following: j "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 subject to Wor an's Compensation laws of California." Signed - ------ - - -------------------------- Owner BYTitle ------- ------ ---------------------------------------------- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY f ------------------------------------------------------------------------- DATE BUILDINGPERMIT ISSUED -------------------- ----------------------------------------- -------- -------------------=--------------DATE ------------- ----. ADDITIONALCOMMENTS ------------------------ -------------------- --------- ------------------------------------------------------- - - -----------------------------------------------------------------------•------------------------•- -- -------------------------------------------------- ---- a-, Final Inspectio ------ � '--------------------------------.Date ---- -7 ----- -------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M