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FOR OFFICE USE: APPLICATION.FOR SANITATION PERMIT (Complete in Triplicate) Permit No. --Z---------------- - �S 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/LOC ION 1-� /-,-.- �----- -- ------ ZCf-- -- ------- ------------------------CENSUS TRACT --------------............. Owner's Na Phone ._ w] -- ------- ------ -------- - - 1.. 1__r.�. ------ Address ------ c -�P- City, ------ -------------- # ------ - -- -- ----- - - - - --- - Contractor's Name __ ___ ___s. ----------------License #aT_71- -�/-- Phone ___f___ ___ _ Installation will serve: Residence RfApartment House ❑ Commercial ❑Trailer Court ❑ Motel ❑ Other ---- --------------------------------------- Number of living units:--,/------ Number of bedrooms --42,-__-Garba9e Grinder ----------- Lot Size __��__--_..- -___--_-_--- Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt]] Clay ❑ Peat ❑ Sandy Loam 4D Clay Loam [] Hardpan ❑ 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.) c NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK' Size___ Y47 �[ & _ p _.-__,_--_- )J[ 7 [ l �----� Liquid Depth . N Capacity 1 � Type -$/tz- Material--&?.zl�s>, No. Compartments _ .-.--------.• D 77 / Dl� Distance to nearest: Well __________s��__________________Foundation __._�__�___.___ Prop. Line __ .._....._......._ LEACHING LINE No. of Lines - Length of Ach lin !' --_ Total Length 'D' Box --/.---.- Type Filter Material __�e _ _Depth Filter Material -----/4:4? ............... ....... �j rn Distance to nearest: Well j Foundation _ '� Property Line f----f,-.._---_-_- SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No C Water Table Depth -------------------------- --• ----------------Rock Size -------------------- Distance to nearest: Well ----------------------------------------Foundation --------------- ---- Prop. Line ---------------------r REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------..--__-----...._._.....--) SepticTank (Specify Requirements) ---------------------------------------------------------------------------------•------------------------- .---------------------------- 6 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 kman's Co ensa�i.on ws of California." Signed --A _-�` -------------- ---------- --------------------•- Owner BY Title C------------------------------------------ ---------------- (If other than owner) OR ARTMENT USE ONLY APPLICATION ACCEPTED BY ---- = -------------------- ----------------------------------------- DATE ` BUILDING PERMIT ISSUED ----- - --- --------------------------------DATE _-- -__-- ---- -------- ADDITIONAL COMMENTS -- --------- ------------------- ---------------- ------------- ---------- --------------------------------------------- --- ------- - -- -- ---- ----- ----------- ------- --------- --------------------------------- ------ ------------------------------------------ //, ----------------------------------------------- ------------------------------------------------------------------------------------------------------------- Final Inspection by: ------- r-- -- ----- -- ."= Date - ----------------------- N�AQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M