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I ' LFFFICE USE: APPLICATION FOR .SANITATION PERMIT Permit No. _72 °-- +----- �__... -{Complete in Triplicate} 7L --------- ,.. Date Issue --- --------- " - - ThisPermit Expires l Year Frog+ Dat issued r S�----- --- - ------ ount Ordinance No. 549 and existing Rules and Regulations: is hereby made to the San Joaquin Local Health District for a permit to construct and install the workherein Regulations- Application I ��g� k•O- 1+cation is made in compliance w+ " described. This app ' , . •,. - ,�J Ir ------------I--•-------- S-o5.1 n .w/ vd7 'i�0�: ---------- CENSUS TRACT JOB ADDRESS/LOCATION. Phone ------- , �-" --------------- ------ ---------- Owner s Name ------ _ --- , City " - �..... ,� :" , Address -------------------------- --- / I Phone _ " _ " License #�-i�- - - t Contractor's Name _ _ ---- -- Commercial❑Trailer Court Residence-. par-tment_Hodse❑_ Installation w�iil_serve:.�:.....-.--�-.- `. Motel ❑..Other -----------------------------------------i-- -------------------------- rooms --------- ii { Garbage,'Grinder j Lot Size a` Number of living units:!------) - N6 mbbr iof-bedrooms:� private ❑ --- Water Supply: Public System and name -- peat❑ Sandy Loam ❑ Clay Loam ❑ Silt❑ Clay ❑ ' Character of soil to a depth of 3 feet: Sand ❑ .r?-. If es,type ----------------- - Hardpan ❑ Adobe Fila'Material -----=_, Yf Yl tion to wekls,�buildings, etc. must be placed on reverse side.l, y [Pl'ot plan, showing size t of lot, location of system in rermitted if public sewer is available within 2DOf}ht,)" � I 1 4 NEW INSTALLATION: (No septic tank or seepage p' p {K. Liquid p No. Compartments PACKAGE TREATMENT '[ ] SEPTIC TANK] size------ -- -- �- T � Capacity ya �a----- Type i Mafierial- - / Cap Yi .w •�,�.'--------------Foundation ---�-�-�-------- Prop. Line " ."_.----•--------- i IDistance to nearest: Well --------- rn7 x - - � Total Length --- ------------------•---- l»--' �. -" - -- ---- ----_ ""-- Length of each line.--,��-- ---- ---: -- �.. y LEACHING LINE {T,� No. of Lines - D' Box,- Q-- Type Filter Material _" ------Depth Filter Mcherial ------ - IAJ)-- ° - Property Line. '�� '�' Foundation . Distance to nearest: Well ---------------- -ff- " t �___ Rock Filled Yes No �[] Diameter Number SEEPAGE PIT Depth - x --- I ---- ^. .Rock Size ��' / Water Table Depth -------- = --------- D �,---- Pro Line -- • - .-� _.".-__--:Foundation '----�----- p• a - _ F f l Distance to nearest: a �---- ------------------ I ) a + � -Date ----k----------------- REPAIR/ADDITION(Prey. Sanitd'ion Permit# - i uire'ments} --------------------------------�-—---- Septic_Tank (S.Rec+fy Req -------- - 1. ------------------------------"_"-.""_�-_""_-_-""_"_-""_""_-"_""_-"""_"_"_"_-""_"""-_"".__"_""- Field1,(Spe �fY Requirements) , ------------------------------------ Disposal+ - 1i ------------------------------------------------- - - Draw ex and required = ------------------------------ -------------------- --- red addition on reverse side) 1 hereby certify that I have pr pared this application and that, the work will be done in accordance with San Joaquin Count Ordinances, State Laws, and Rules and Regulations of the San Joaquin LocaliHealth District. Home owner or liten- Y sed agents signature certifies the following: permit is issued, 1,shall not employ any person in such manner "I certify that in the performance of the work for which this p s as to become subject to Workman's Compensation laws of California." 9 --------------- Signed i Owner Si ned ---------- -- �` - • ------- ---- Title ----- ---- ---`'r'---:- - -i"-`-------------'---------- (if " --." BY " """ (if other than owner) f + I FOR DEPARTMENT USE ONLY ] DATE =l T = � - - 1 ---------------DATE ------------- APPLICATION ACCEPTED BY#-- -.... - BUILDING PERMIT ISSUED _-"f-__. -- ---- -------------- ------- ------------ -------------- ADDITIONAL.COMMENTS �� r7 `7' ------------------------ --- --- _ - ---- -- ---- -- --- - ---' _ wJ f _ i`----------------------------- .' _: �- -•------- ._ _Date -- - �> --------- �--µ-'-,-�------ -------- - - -------- Final Inspection by: ----- -- SAN J AQUIN,:LOCAL HEALTH DISTRICT r W 4 1-'68 Rev. 5M. - -