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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT permit No. --7 3�' -------------------------- `� S ,Complete in Triplicate) ---- ----�-------- � pate Issued _�-�7�-�- t - ----- - ---- ------ r . This Permit Expires ] Year From Date Issued - ------- ----- --------------------------------- with Co my Ordinance No. 549-,and existing Rules and Regulations: Application is hereby made to the San Joaquin oaNHealth District for a permit to construct and install the work a herein pP lication is made in compliance described. This app NSUS TRACT _ IYA-11Z�71_ ,108 ADDRESS/LOCATION �. phone ------------------------------------ -- "------ -----------•----�--'"'----- , -- - Owner's Name -- �' y�OfA_0�C;t6? -_---- '� --- _- Address __ � ------.Lice nse #a7�a/ ,Phone - ` Qt! ` Contractor's Name ----- installation will serve: Residence I Apartment House❑ Commercial ❑Trailer Court ,❑ Motel ❑ Other -------------------------------------- 4 - f �� Lot Size � -------------------- Number ---'-- ----•--•- # Garbage Grinder _ _ -__- -- �`��"" -`" Number of living units:--"/".-- Number of bedrooms --��---`---- ___-""""Private Sandy Loam _____-_" - ------------------------- ------ ' Public System and name _----------------------- --- ---Cla 1 Water Supply: Y Peat❑ "---- if Yes,typ ❑ Clay Loam ❑ i Character of soil to a depth of 3 feet: Sand❑ S;It❑ Y ❑ ] Hardpan ❑ Adobe Fill Materia e `� win size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.} (plot plan, sho g i I NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) `n f Size -------- Liquid Depth ---------------- ---------- PACKAGE - ---•-- V' pAClCAGE TREATMENT [ ] SEPTIC TANK [_1. . ..� . ._.: - . _ ,-.. , t 'Capacity fi __ Type -------------- ----- Material-------------------- No. Compartments ---- ------•---------- Prop. me Distance to nearest: Well ------------- Foundation ------------ No. of Lanes Length of each line---------------------------- LEACHING --------- ---------------- Total Length -------------------------- i i LEACHING LINE [ ) _-------------" Type Filter Material -------------------- ----------------- -Depth Filter Materia D' Box ____- ----- YP ---- Property Line - -"-""-- Foundation ------------- ----- `-' ------ Distancetonearest: Well ----------------- Rock Filled Yes ❑ No `0 i SEEPAGE PIT [ ] Depth Diameter Number --_------- , -Rock Size ---- Water Table Depth ----------------------------------------------- ----- ----- ------ ----- --------------------- ---------------------------- $ Foundation k-------------r' Prop. Line Distance to nearest: Well ----------------- -- -----_ I a • - --- ------ - Date - -----------------•-------------- - __... REPAIR/ADDITION(Prev. Sanitation Permit# --------------------- '%"' _r ---- _ _ ,� _ � ------ - _ ,01 Septic Tank (Specify Requirements) .--------- Field (Specify Requirements] -----� *� i:. 'T ) Disposat Fie ( P r �! ----------------- - ----------- --------- ------------ � (Draw-ex isting--and-required addition on reverse side) be done in accordance h San Joaquin I herebycertify that I have prepared this application and that the a Joaquin Local Health District. orne�ow.ner or l ten County Ordinances, State Laws, and 'Rules and Regulations oft e sed agents signature certifies the following: { permit is issued,.I shall not employ any person in such manner "I certify that in the performance of the work for which this p as to become subject to Workman's Compensation laws of California." i Owner Signed --- ------ ----- --- --- -- ---- --- ----------- --------- Ao --------------------- ------------ Title ----------------- - (If other owner) E . FOR/DEPARTMENT USE ONLY --------------------------- --- DATE -- -�-- - ---�-- -- - ------ := DATE APPLICATION ACCEPTED BY _----- -- - s - ---------- P ----------------=------- BUILDING PERMIT ISSUED --------- ----------------------- y. --- ------ - _ _ ADDITIONAL COMMENTS ---- -------------------------------�-------------------------- _r - 't- ` � 7 73---------------------------------------------------- ---- ------ -------------- ----------------------------- = f ---------------- ------------------- - -- -- ------ Date -------- --- -------------------------------------- -- Final Inspection by: ----------- -�-` SAN J AQUIN LOCAL HEALTH DISTRICT U 1 68 T.V. 5M �: � -SV�l �