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- USE: FOR OFFICE' e APPLICATION FOR SANITATION PERMIT p -------------- - --- ----------- --------- I`- -- Permit No, ` I (Complete in Triplicate) ------ - I----- _ cc�? ________ ___ _____________________________ _ __�______ This Permit Expires 1 Year From Date Issued Date Issued � --------------- Application �1---73 �N Application is hereby made to the San Joaquirl Local Health District for a permit to construct and install the work herein described.�This( plica ism in co is ith ounty Ordinance No. 5.49 and existing Rules and Regulations: JOB D1�E /LOCAI�OIV` ------------- - ----- -------- -- ----- i ------CENSUS TRACT -----------------------•-- Owner's Name _ Phone .4. Address �� -'--�1L -- Ciry _ ty7� V -------� _ �------ Contractor's Name E - - -- - - - License # � Phone--- ----------- Installation will serve: Residence Apartment House Commercial ❑Trailer Court ( ---- . ❑ I I Motel ❑ Other 11� Number of living units:---%------ Number of bedrooms _%3------Garbage Grinder -A)O.- Lot Size _i5_ /______________ Water Supply: Public System and name -------------_-------------------------------------------------- ------------------------------------------------Private d Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ m Hardpan X Adobe g Fill Material ------------ If yes,type ---------------------------- 0 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) } NEW INSTALLATION: IN� septic tank or seepage pit permitted if public sewer is available within 200 feet,] y ` PACKAGE TREATMENT [ ] SEPTIC TANK.p4 Size__' _: ._.__ ---------------- j k it �--� 9--------------- Liquid Depth ---�------------------ Capacity _ � Ca acit AN�0 -- __ Type aterial- _ o. Compartments p Y YP - -�s� v ............... Distance to nearest: Well _ (0-0_�-------Foundation ___________ Prop. LineZ44 i LEACHING LINED4 No, of Lines-------C�) _ _____ Length of each line____ ___ Total Length ____00__ ____________ 'D� Box j_ _._____ Type Filter Material �_`__ ______Depth Filter Material - __---------------�! Yp •----------------•------ Distance to .nearest: Well APO 70-- Foundation ---16--------------- Property Line, _ __ _ __ ___ II �� ______________ Rock Filled Yes 5E No i❑ > SEEPAGE PIT Depth ___��._______ Diameter ____x��-- Number _.__-_.�- Water Table Depth ------------------------------------------------Rock Size -------------------------------- I' '7�..� Distance to nearest: Well _ 9 / __ .__Foundation-=-_� P_--_____ Prop. Line Lc a REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date______________----________________] Septic Tank (Specify Req11 uirements) -------- ----------------------------------------------------------------------- -,------------ r Disposal Field (SpecifyRequirements] i ---------------------------------------- 1(-------------------------------------- -------------------------------------------------- ---- ------------------------------------------ ------------------- 11 ' -------------- --- ------------------------- ------------------------------------------------------------ -------------------------------------------------------------------------------------------- (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. Home owner or licen- sed agents signature certifies the following: "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 Workman's Compensation laws of California." Signed -- -_-_ -- --- 6YlC __---___ Owner - - ---- -- 11 1 k BY ------------ ---------- -Title ----- ! (If other than'1owner) f FOR DEPARTMENT USE ONLY ,I APPLICATION ACCEPTED BY ----- '-- DATE ------------------ BUILDING PERMIT ISSUED !I: ---------- DATE ----------------------------------------- I ADDITIONAL COMMENTS J_______________ - ------------------------------------------------ ------------------------ -------------------------------------- } � - -------------------- ---- ------ --------- I Final Inspection by: --------------------------------------- i ------ ----------------------------------------------------------------------------------- ------------- - --- -- - - ----- --------------------------------------------'------------------------------------.Date SAN JOAQUIN LOCAL HEALTH DISTRICT H. 9 1-'68 Rev. 5M a�