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FOR OFFICE USE: F, APPLICATION FOR SANITATION PERMIT } ..............:..... Permit No.73-..4 (Complete in Triplicate) ..............................- i Date Issued _. ....-1�. 7. ................................•--.-...---...__..... This Permit Expires 1 Year From DoWissued iApplication 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/LOCATIO ........ ...... CENSUS TRACT� r ---- PhOwner's Name Y. ----..... Address --� .. city .................�...s.. �..-.........�.. �. Contractor's Name . ................. . ..� --.License #,P Phone Phone Installation will serve: Residence gApartment House❑ Commercial ❑Trailer Court :❑ 'Motel ❑Other ..................•------------------.. .- i Number of living units: Number of bedrooms ----X-_.-Garbage Grinder Lot Size .....A__..._..--•---" ................ Water Supply: Public System and name ....- _.... ------------------ •--------- -------Private ❑ Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ..--.....- If yes,type ........... .............. \ (Plot plan, showing size of lot,I location of system in relation to welts, buildings, etc. must be placed on reverse side.) Q` NEW INSTALLATION: (No septic tank or seepage pit pgrmitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ SEPTIC TANK j }F_'/V SP,size----------------..-------------------- --- Liquid Depth ----.................... Capacity Type -------------------- Material....-- ----- No. Compartments Distance, to nearest: Well Foundation ........."------- ---- Prop. Line ...................... e LEACHING LINE No. of Lines Length of each line --'`i�0. ......... ..." Total Length ....fx� .__.._.._...... D' Box ..... ... . Type Filter Materi I . .._.__....Depth Filter Material _.lf�........... ...................... Distance to nearest: WeII _._ __ undation l --f._....._ Property Line :..��` _-...�.....:_. SEEPAGE PIT Depth o1�4`r.------ Diameter Number . _.. ..... .-"- Rock Filled Yes No Q Water Table` De th .......... --------•------------------Rock Size ..-- Distance to riearest: Well ..../ -------- ------------Foundation -...... Prop. Line -.- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ------------ .......... Date ---------------------------------- Septic ------------------ -----Septic Tank (Specify Requirements) . --r-• ! p --------- j' � " """"""'"""""Disposal Field ecifequirements) .___. I .................. .......... ---...............:.... ........... ....... . ....-- (Drdw 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 Son Joaquin Local Health District. Hone owner or sed agents signature certifies the following: i "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such-manner as to become subject to Workman's Compensation laws of California." Signed .:_...._... .............. 4�-- Owner ---.--.. ---- •---- --- Title _..... .. y (!f other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 8Y .........'W - .- ' �._.- c1'...... ......_ ......... :,:...._.... DATE ... ..G�._!..-..�. .......... BUILDING PERMIT ISSUED ------------------ ------------- ... ...... .....DATE ........ -----------._ -•--•--.._... ADDITIONALCOMMENTS ............ ----------------------------- -----•----•- . ......._...----•-. ......----•...----•- ym„.............•_........... ............ •----- ---------- --- ---- --- -•---------.... ...-----...--- .......-- .......... ............ :.......................---...._......_.._....: ` Final Inspection by: � - - - -------- ---- -------------------•-•...------ -- ........ ---------------- Date _. 4 SAN JOAQUIN LOCAL HEALTH DISTRICT A' -e-..rr- 3.- 2fi, .. i.a oma_. a •,_.... _ _