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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------- ---------- ------------------------------ ;Complete in Triplicate) Permit No. ---73----------- 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 with County Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION . G 11_ ' --'L-�/-,----------------- --- ------- -?z�----CENSUS TRACT -----' Owner's Name _ 't7_a —-------------------------------------------------------- ------Phone --- �f , - = Address ........ / � ----_---------=------------- - --------------------- -----------. City ----- 'SfG' fp l-----------------•----------•--••----- Contractor's Name /-a- _ rC�-_ -_---------- ,_ �i__ �`l� - '-----License # ��9��---- Phone -------—------ Installation will serve:. Residence EN Apa—rtriment House❑ Commercial❑Trailer Court i❑ Motel ❑ Other`---------- -------------------------------- 40 Number of living units: _ --t__ _-___ Number of bedrooms q" 9 ___Garba a Grinder ---------- Lot Size Water Supply: Public System and name ------------------ ----------------------------------------- --------z--------------------------------------Private Character of soil to a de �h of 3 feet. Sand Silt Clay Peat Sand Loamy -Clay Loam p� ❑ ❑ Y ❑ ❑ Y ❑ Y ❑'. Hardpan ❑ Adobe PV Fill Material ------------ If yes, type __________________________ } (Plot plan, showing size of lot, location of system in relation to we buildings, etc, must placed on reverse side.) F NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size------------------------------------------ ---- Liquid Depth ------I------------_------- ------ Material---------------------- No. Compartments .---- Capacity ----------- - Type ------------- -----.---------- p Distance to nearest. Well ----------------------------------- Foundation ---.------------____-- Prop. Line --------- ..:.,____-- LEACHING LINE No. of Lines ---------/------------- Length of each line---------- ----- Total Length _--- ____________ T 'D' Box ------ ---- Type Filter Material --------- ........Depth Filter Material __________l _________________________ r � Distance to nearest: Well`_____/___Qt2__f__ Foundation ------14-1-)---- Property Line _ . Number _____--- Rock Filled Yes No SEEPAGE PIT' Depth __.__ - r_--_ Diam �_ eter __ �� -- ------------ � Water Table Depth ------------ ---d------------------------Rock Size ------ � ------------- I i ' i � Distance to nearest: Well ______ ------------- 'REPAIR/ADDITION(Prev. Sanitation Permit# ---•---------------------------------------- Date ----------------------------------I Septic Tank (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 become subject to Workman's Compensation laws of California." Signed ------------------------------------ - ------------------ -------- '- --------------------- Owner Title ------ BY -------------- ___ _ � - 8� _.__ (If other than owner) FOR DEPARTMENT USE ONLY p APPLICATION ACCEPTED BY -- - ------ DATE / ----- BUILDINGPERMIT ISSUED --------- ------------- ------------------------------------------------- --------------------------------DATE -------------------------------- ---------- ADDITIONALCOMMENTS ---- ----------------- ---------------------------------------------------------------- ------------------------------------------ --------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- :------------------------------------------ --------------------- --------------- --- ------------------------------------------------------------------------------------------------- --------------------------------------------------- ----------------------- ------ - - ------ - - r� Final Inspection by: _.__-- _ -- - Date -__ _-- _ _ - ---------- --- SAN JOAQUIN LOCAL HEALTH DISTRICT F H 9 1-'68 Rev. 5M