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FOR OFFICE USE: 4r APPLICATION FOR SANITATION PERMIT ---- (Complete in Tri Iaate) Permit No: ". -`-� -�-' ------ r P P ---------------------------- om ----------------------------------------------------- ThisPermit Expires 1 Year From Date Issued Date Issued j(— "73 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 Cou ty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION - - " Bd� - ----------- --------------- - ---�- SUS TRACT -.------••-----........... Owner's Name -""-- -____ � � - F.r..� -------- I 2 _,� _ v Phone ---------- Address - -7- - -------- -- - � � " . City - ---- Contractor's Name --- # 3crl ---- ----- Phone .- Installation will serve: ResidenceApartment House, Cornmercial ❑Trailer Court ;❑ '' Motel ❑Other ------------- �.. ` ----- Number of living units:----- ----- Number of bedrooms ---•Garbage Grinder -_____----.- Lot Size -_-"." ----`---- `—`=---- ' Water Supply: Public System and name ---------------------- Character ----------------- ---- [\ - - - --------------------------------------- --- - - ----- - - " Private - - - - - ----------------------- - Character of soil to a depth of 3 feet; 1',Sand'❑ Silt❑ Clay ❑ Pelt❑ Sandy-Loom [� Clay-Loam:❑ Hi�`rdpan ❑ Adobe.0 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.) �h! NEW INSTALLATION: (No septic tank or seepage pit permitted if public,sewer is available within-200 feet,J PACKAGE TREATMENT —. [ ] SEPTIC TANK Size------------------ [ I �. ---- ------------- ------------ Liquid Depth -------------------- Capacity --------------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 "----------------------:Foundation -."-- '__ Property Line -"""_-__._____ SEEPAGE PIT _ Diameter _---_ ___-_ Rock Filled Yes ❑ No CI Depth F Nu tuber --------------- Water Table Depth ------------------------------------------------Rock Size ------------ Distance tot earest: Well --------------------------------- ---Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ---.-.---------------------------�,___"_-- Date ------------------•-------•--"_-_ Septic Tank (Specify Requirements) ------------------------_-_ Disposal Feld (Sp cify Requirements) --_ � --------- = 4.................................................... ------------ ----------- ---- - --------- - raw 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 ofEthe work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Co ensation laws f California." Signed ---- -------- --. " Owner ------------------- ------ --- ------------ --- "R BY tle -` - tct --- (If other than owner) ------------ ------------ FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED. BY__ ._._ :_- DATi: "� ---10 -----------•- BUILDING PERMIT ISSUED --"_ ----------------------------------- ---------DATE ---- --------------------------- ITIONAL COMMENTS ..... _........ _'_-__- ----------------------- --------------------------------- ---------- - ------- ---- ---- --- ----- ---- Final --------------- ----- ---- -- ------------------------------------------- ------------- --------------- Final Inspection by: "--_- _ �._ ---•----------••----- - -----------.Date ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M IA...