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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 73 any {Complete in Triplicate) Permit No. --------------------- - __________________________ This Permit Expires 1 Year From Date Issued Date Issued ._ ? 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 withAunty Ordinance No. 549 and existing Rules and Regulations: s. JOB ADDRESS/LOC ON ------------------ C== - -------- `C�c� � P--- CENSUS TRACT --------- Owner's Name ------------ ,(�`-`t- �-- -------Phone ------------------------------------ r• r Address // 75- 5 ---- J 17 7 ----�J - -y'v fZ4L City ----- --------------------------------- Contractor's Name License #�� 3Y Phone Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other -------------------------------------------- Number of living units:----- Number of bedrooms s__'7;2:-)------ Grinder ------------ Lot Size Water Supply: Public System and name ----------------------=--- ----------------..._------...-----------------.-----.------ Private Character of soil to a depth of 3 feet: Sand'❑ Silt F] Clay ❑ Peat❑ Sandy Loam .E] Gay Loam ❑ Hardpan [ J 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) I PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size----------------------------------- ------ 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 ________________________ f=oundation ------------------------ Property Line ______________-___._____ SEEPAGE PIT Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes No CJ Water Table Depth ------------------------------------------------Rock Size ------------------------•-- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -.------------------_. REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ..................................I SepticTank (Specify Requirements) -------------------------------------------------------- ----------------------------------------------------------------------------------- DisPosal Fiel pecifY Requirements) - --- ---- -------- ---•-- ----------------09 r - j ---L - -----------------------_________________ _ _ ______________________-___-.________________.______.____-__-_____-_________-______________________________________________________.______- (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." B ned ---= ---------------------- 1.L4� , �=V :�a _,� Owner .. Signed ---------- Y -------------------------------------- 4 � L✓. (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - .L ------------------------- --------------------------------- DATE ` BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ----------------------------------------- ADDITIONALCOMMENTS --------------------------------------------------------------------------------- ------------------------------------------------- --------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- --------------- J � Final Inspection by = = E Date . SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M W}a