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• r FOR OFFICE USE: APPLICATION FOR--SANITATION PERMIT - ----------------------------------- 2 -- --- (Complete in Triplicate) Permit No. ---------=---- ------------------------------- /� 73 ----------- This Permit Expires I Year From Date Issued Date Issued _. 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 �Wles and Regulations. JOB ADDRESS/LOCATION 7�/ ---! ------CEN US TRACT -------------------------- Owner's Name ! .ri�l� --------- ----•-------------------------------------------------------Phone ---------------------------------- Address Q , r = -I f s� ___--`--- city .��s�lF' �_��r� �'!'� ' Contractor's Name _.__ � _ f --- ° a -=-------License # .rr07,3- Phone Installation will serve: Residence ❑Apartment House❑ Commercial : Trailer Court ;❑ Motel ❑Other -----"- -------------------- �y Number of living units:_____ Number of bedrooms _______Garbage Grinder ----_.____ Lot Size _ __ Water Supply: Public System and name --------------------------------------------------------------------------.-----------------------------------Private 0 Character of soil to a depth of 3 feet: Sand'X Silt E] Clay ❑ Peat ❑ Sandy Loam -❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ 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 [ ] Size_____" _ ?C_ 1 __ --------- Liquid Depth _4 ------------- - 0 Capacity _ ___ Type{'�-akv_Material_4::� No. Compartments ----- ------ N Distance to nearest. Well ____10 ___ '______________Foundation -�®____________ Prop. Line ________----------- N "`__ ... ��LEACHING LINE [ ] No. of Lines ...,�-------------- Length of eachsline____.�Q_------------ Total Length __._.._______. D' Box _ Type Filter Materia( y_ ____-____Depth Filter Material ___ ---__________________�..,__.___... Distance to nearest: Well/40g--"_-------- Foundation 1--.000--------------- Property Line -_______-------- r SEEPAGE PIT [ ] Depth --------- ---------- Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ No ❑ WaterTable Depth ------------------------------------------------Rock Size -------------------------------- V74 Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line _._._.__..____------__ REPAIR/ADDITION(Prev. Sanitation Permit=# -------------------------------------------- Date ----------------------------.-----) - v SepticTank {Specify Requirements) --- --------------- --------------------------------------------------- ------------- --------------•---------------------------- Disposal Field (Specify Requirements) --------------------------------------------------------------------------------------------------------------------- --------------- - --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------ ----------------------- -------------------------------------------------------------------------------------------------------------------------------------- (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 beco a?subje t t Workman' -Compensation laws of California." Signed04,_. ' J ,t/_ E' ----------- Owner r' . -$:- By ---------- ----------------------- Title .r (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _.______ ___ ________ __ ---------------:-- DATE BUILDINGPERMIT ISSUED ------------------- ----------------------------------------------------DATE -----------------------------------------•- ADDITIONALCOMMENTS -------------------------- --------------------------------------------------------------------------- --------------------------- --------------------------- --- - -- - --------------------------------------------- ----------------------------------------------- -------- -- - --.- - - -- - ---- Final Inspection by: ------ -- - - -- ------- -- - ---- ----------------------------------------------------------------- -Date v v SAN J AQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M