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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: ____-3-�-�-`7� , -----------------------------------'------- -------------- i (Complete in Triplicate) ---------- --------------------------------------------- Date Issued - -9--------/----7-3 This Permit Expires 1 Year From 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 iin complia`n�ce�with County Ordinance No. 549 and existing Rules and Regulations. % JOB ADDRESS/LOCATION !-7--16-- �`` ----f2 y r�1 CENSUS TRACT . fif Owner's Name ---- /�----5;47 _lvdl.�XS---- ----- --_-•-------------------Pho e ------------------ -- --- --- Phone c� - 9 -------------j---- - �,,,� Address 4 /1� 1 ,/f��4 C --- ----------- City X �Zi E' ------------------------------------------- ------- ----------��---------- -- -- I . -` ' ! - l License _T / Phone , ' l Contractor's Name ___ _" I I Installation will serve: ResidenceApartment House❑ Commercial ❑Trailer Court ;❑ IMotel ❑ Other -------------------------------------------- Number of living units:_________ Number of bedrooms _ ---------------------- -------- - ,.�_"_ _""--Garbage Grinder ------- "-._ Lot Size ------------`--------------------- -- R Water Supply: Public System and name ------------------------------------ --------- ------------------------------------------- Private - ------------- Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ d SHardpan ❑ 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.) , NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available wi in 200 feet,) ' ----------------------- \1 PACKAGE TREATMENT { ] SEPTIC TANK�[ ] Size----Mater' I------ -------------- """"o. Compartments "___�____ ---------- �! I Capacity -------------------- Type -------------------- Distance to nearest: Well ---------------------------I- - -----Foundation - _- ---- ----------- Prop. Line ------- ------------- Length of a line---------------- ----------- Total Length --------------- LEACHING LINE [ ] Na. of Lines ,_._______ -------------- g """""-""""--- 'D' Box ------------ Type Filter Material --- ---------------Depth Iter Material -------------=------•------------------•• Distance to nearest: Well ___._-"---------- ----- Foundation Property Line -------------------••- SEEPAGE PIT [ ] Depth ----- ------ Diameter _____ __________ Number -----------------------=-- Rock Filled Yes ❑ No I❑ I s Water Table Depth -------------------- ------------- ------------- ock Size -------------------- ------ Distance to`nearest: Well --------- __..Foundation -------------� -- Prop. Line ____________-----..--- i REPAIR/ADDITION(Prev. Sanitation Permit# -------•---------- Date ------------------------ : 1 Septic Tank (Specify Requirements) -------------------- --- DisposalField (Specify Requirements))�__ -- -----"� / "" - /la- S -------------------------------------------------------- Iq ------------------------------------------- ------------------------------------------------- -------- ---- -- - - - - - --------- {Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that the work will be done in accordance wish 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, t shalt not employ any person in such manner as to become subject to Workman's Compensation laws of California." ----- ----- --- - -Owner ------------ ------------------------ Title ---- ------ --------------------------------- --------------------------- (If er than owner) FOR DEPARTM T NLY Q' = ----`�-- DATE -- ---- `7 -------------- APPLICATION ACCEPTED BY --------------------------=--- -- ---------- -- __ -------DATE BUILDING PERMIT ISSUED ---------------""_--- -- ------------------ ADDITIONAL COMMENTS ------------------------------------ ------ -_ T 73 -- ------------- - --- - Final Inspection b ___________.Date ---- - SAN JOAQUIN LOCAL.HEALTH D TRICT k Cb I E. H. 9 1-'68 Rev. 5M