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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---- -- - - - - Permit No: ------73�3.b ---------------------- (Complete in Triplicate) i Date Issued -_� - '--7 ___________________ _________ ___ _________________ This Permit Expires 1 Year From 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 Rules and Regulations: JOB ADDRESS/LOC I N .17 T.3 - --------------------------------------------------CENSUS TRACT ------------------- W ------------------ .... Owner's Name _""r _ _ -----------_. ------------------------------------------Phone`f 77-=1-`f 9 ------------ Address ---------------- ' `�� - ----- - --- Y -------------------------- Cit ----- ----- - -- ------ --------------------- Contractor's Name . _-- - -_- -- -----F_;---------- --------.License # -- r�------ Phone - �P--- ----------- dr a�7 Installation will serve Residence-1. t House❑ Co�,mercial-❑Trailer Court ❑ Motel ❑Other --- ----------- ---------------------------- I , X f .� Number a# living units:---- -_---- Number of bedrooms ___ -Garbage Grinder ----- --- Lot Size _- __ -- -- �------------------ J t f _ Water Supply: Public System and name ------------------------------------------------ ---- -_ :�•:' Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ F Clay ❑ 'Peat" Sandy Loam -E] Clay Loam E] Hardpan ❑y""Adobe`6 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-- _.-_-_--_-_----------------ts -- -------- Liquid Depth -------------------------- Capacity -- ------ Type --------- Material " ------------ No. Compartments Distance to nearest: Well --------' -----------------------Foundation -------------------- Prop. Line _-.--_-------_-_---_-- LEACHING LINE [ ] No. of Lines __-'--------------------- Length of each line------------_--- -- Total Length D' Box ----.------- Type Filter Material --------------------Depth Filter' Material --------------------------------------- Distance to nearest:-Well--"__ ----- Foundatibn=-------------'--.-------- Property Line_ :--__.-.--_---.-------_ SEEPAGE PIT [ ] Depth Diameter Number ---------=----------- Rock Filled Yes ❑ No C Water Table Depth ------------------------------------t,._E-------Rock Size ---------------------- Distance to nearest: Wel! ---------------------------6-_---_-:1--_Foundation---------------------- ---------- Distance Prop. Line --------_-_-____.._-_ ; REPAIR/ADDITION(Prev. Sanitation Permit# -------- --`------------------ -----------Date ----- ------------- Septic Tank (Specify Requirements) .. ° - 1 ''"} ; e,J s Disposal Field (Specify Requirements) ---__ J-___--- - 1---v---------------------- ------------- ------------- ------------- --------- -- 4*---- r (Draw existing-and-required addition o rn everse side) I hereby certify that I have prepared this application and that the work—WI'be- done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin E cal 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 -------------------------- ------- Owner � _ - . --------- ---------------------------- By --- , -7itie - - ----------------------------------- { =4_ cn owner] sirs FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- DATE = ?. BUILDING PERMIT ISSUED ------------------------------------------------ ------------------------------------------------- DATE ---------------------------------------- ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------=---------------•----------- ; --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - --------------------------------------- ---------- ------- ---------------------- / ---------------------------------------- - ------------- ---- =/ -------------- Final Inspection by: --------- ------------------------------Date --- SAN JOAQUIN L CAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M