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.rFOR=OFFICE USE: • APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit,No: .7/-J-73_. .71--J-73- ------------ -------------- ------------------ - I Date lssuecl'-/ 7/._.. i _____________________ f This.l'erniit Expires 1 Year From Date Issued fApplication 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. 5.49 and existing Rules and Regulations: JOB ADDRESS/LOCATION - - '7` / lel '��,�/ - SUS TRACT" f Owner's Name -�--- :.. - _. -� -•' - - - ._Phone-------------- -- --- --- ---- - -------•---- Address s-.t r / .. .r , -- 8 -E�' / �� City----- i Contractor's Name L -'� License #� i _ Phone �, /-� --------- _ Installation will serve: Residence XApartment.House❑ Commercial ❑Trailer Court i❑ `~ Motel ❑Other _.__________ _ _ _ _ r � 1 - 1 Number of living units:_______ Number of..bedrooms '-arbage Grinder 410ZLot Size _�"ff' --=__________________ Water Supply. Public System and namef ----lr----=------------------------------------------Private ❑ Character of soil to a depth of feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom ❑ L Hardpan ❑ Adobe { Fill Material -------------If yes,type ---------------_------------ (Plot plan,,sFiowing size of lot, location of system in relationto wells, buildings, etc, must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit perm tied if public sewer is available within 200 feet,) . / PACKAGE TREATMENT [ ] SE PTJC T NK Size_-_ __ f X0--------- ____________ Liquid Depth Yp Capacityf . _ T e __f_' Material--e,4r-�°*---____ No. Compartments _ _______________ W � �-- Distance to nearest: Well __""r--___________________Foundation -`X�--------- Prop. Line ___1 LEACHING LINE No. of Lines ____ ------ ___ Length of each line---_94`-------------- Total Length 'D' Box ]y Type Filter Material/je�Depth Filter Material ;/ _-___________________________ Distancee�o nearest: Well __ '� __---_-- Foundationy� Property Line -________--------------- i a SEEPAGE PIT �1) Depth _ — ---- Diameter t _�� Number -_ --__________________ Rork Filled Yes No / Water;Table Depth --- Rock Size --� Distance to nearest: Well ________________________________________Foundation -� ------ Prop. Line _ 0 ----._--------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ____________----_______________-__) Septic Tank (Specify Requirements) -------- -------------------------------------------------------------------------•---------------------------- Disposal Field (Specify Requirements) -----------7------------------------------------------------------------------------------------------------------------------------- ( -------------------------------------------------------- ----------------------------------------------------------------------------- ----------- ---------------------=-------------------------------- t i i : ^? (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 Distrlct. 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 p rson in such manner as to become subject to Workman's Compensation,.Iaws,of-California."_,,,___ Signed ---- --------------------- --- ---------------- Owner 1 By ---------------------- ---------- --------- /1V '----- ----------------- Title --- � "---------- (If oth an owner(-;, i _ r- I ` FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ---------- +--------- ------------------------------ -- DATE - -'eVAXa --------- BUILING PERMIT ISSUED -'` DATE ------ - --------------------------------- ADDITIONAL COMMENTS -2 � "I------------- ��` �� V =-------------------------------------------- -------------------------------- - --------------------------------------------------------- --- --------------------- - - ------------------------- -------------- - - ---- c.� - ------_ ------------------------------------------------------------------------------------------ ------------------------ ---- Final Inspection by: - _ _ Z-e--__-`-- -- - ---------- ---- ---------------------- - --------- ------------------------ Date -----�__--�-�--..".�7 ---- - ------- 4rSAN JOAQUIN LOCAL HEALTH DISTRICT t E. H. 9 1 '68 Rev. 5M }- " •`� 14