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: 'MrTxF�JR OFFICE USE: APPLICATION FOR SANITATION PERMIT ' 73 ._. .................. 1 Permit No, ............ ........ . . ..... (Complete in Triplicate} � � Date Issued -_...,.••.,---„_.•,•.-,•••- This Permit Expires VYeaw From bate Issued "eApplication 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 .- - .-iv'� , :.. AN. --.Y,:.: ,,..��......................CENSUS TRACT ...... ................... Owner's Name. ......._... ' ..... f l�M.c� Q L� ....................... . ....................................Phone ...................-..-............. Address - fli. & ?.-- irn ...------------------------------ City S`S ?. ...... -•....................................... Contractor's Name ........... License # ''3 - Phone "t-6 t Installation will serve: Residence [Apartment House,❑ Commercial ❑Trailer Court C] r s Motel ❑ Other ............ ----- Number of living units:.... :`-.- Number of bedrooms __c __..Garbage Grinder ...._._..... Lot Size ............................................ Water Supply: Public System and name _..• �' - :,,- Y _:_:_:_ .......Private ❑ i Character of soil to ardepth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe (Pi 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'see a e it permitted if public sewer is available within 200 feet,} �ir.` p p 9 P PACKAGE TREATMENT f ] SEPTIC TANK[ ] Size............................... ................ Liquid Capacity - ;. Type Material........-... .......< No. Compartments,-.”...................• VI Distance to nearest: Well ..................................Foundation .._...._....._........ Prop. Line -----------------.._.. LEACHING LINT: [ ] No. of Lines g i w ---...-.-. len #h of each line ... .. total Length ._.a ._.-.-,-:--........ 'D' Box --- i. Type Filter Material ....................Depth Filter Material .....-......----------I..: .._..-•- •----•-- Distance to nearest: Well -------=---------------- Foundation Property Line ------ -------- SEEPAGE PIT ( ] Depth .___.._ Diameter ................ Number - _._ ....<......,...... Rock Filled Yes 0 No ❑ Water Table Depth ..--- •-------•---........Rock Size .......................... ..... Distance to nearest: Well ....__................................Foundation ---.-_..... ........ Prop. Line ---•----------__---__ l REPAIR/ADDITION(Prev. Sanitation Permit# --------. ..................... Date '-y i Septic Tank (Specify Requirements) Disposal Field (specify Requirements) -------------------------------- ----- ---- ------------. ............... = ____ -----. Q ......... •---------------- ------------------------------- ------- .............. .......... ............... ............. (Dra'w 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 [icon- sed agents signature certifies the following: ,_1_\ l "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person insuch manner as to become subject to Workman's Compensation laws of'California." Signed _:_ . . .. .. . _. ------- ........... --------• -------•--- ----------------- Owner Title . .. ......... ..:...................._. (I other than owner) FOR DEPAR MENT USE ONLY APPLICATION ACCEPTED BY ....... .' � - ......... !z G 3 �....E�_- - ••....... ..........................•--... DATE _. .... ...._...---- ....._...-----..._... BUILDING PERMIT ISSUED ..........__- ----- = .......... ........_-DATE ADDITIONALCOMMENTS --- ----- ---------------------------------------------------------------------- -- ..................... .......................................----------- ...--------- ----- ` ......---- .. ............. .' J ................. ........................... --- --- . .. .... --- ----------------------- P Final inspection by: ... ---------------------------gate ...._.: k ° SAN JOAO IN LOCAL HEALTH DISTRICT f E- H_13 24 1.'68 Rev. inn 7/72 3 M .: