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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 73_ 71� --------------------------------------------------- u Permit No. ---------- --------- (Complete in Triplicate) ----- ----I--------------------------------------- �. ,. Date Issued -�3 -7.. This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local.Heatth-District for a permit to construct and install the work herein described. This application is made in compliance with County Ordina a .o. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION 41.5?1;,�?------- �� f `" " r ----CENSUS TRACT __J_4/7------------ Owner's Name ----- --- Phone ------------- --------------------- Address --------- -------!-----------------. City _ 1d1 ►} ,c--------------------- -----------------•------ �e - f� -------------License #0_/Y - o Contractor'shame _.____ _ - ��/-��- ------------ - ----- 1 Installation will serve: Residence ❑Apartment House^❑ Commercial ❑Tra' r rpt Motel ❑ Other ----------------- ----- :n-.-------------- �. Number of living units:... ----- Number of bedrooms __"__ __...Garbage Grinder _ _ Lof Siie ------------- Water Supply: Public System and name-------------------------- -- -------------- ----------------------------:-----...------ Private,Q ` Character of soil to a depth of 3 feet:- Sand'[] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam '❑ /Hardpan X Adobe [I FRI Material _________If yes,type ---------------------------- (Plot plan, showing size--@f•lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No , tic p tank or seepage pit permitted if public sewer is avdilable within 200 feet,) se PACKAGE TREATMENT [ SEPTI TANK+ Siz:4_ MateriaI_a1r_&0,�_ 1)quid Depth- -- -- Type No. Compartments ------------- Capacity/42 _ .: . _. Pro Line \N Distance earest: Well - -� -------------Foundation -- - --- - p• 0s LEACHING LINE [ No. of Lines _/------ d----- Length of each line,/O, ---- ------- Total Length ` ---------------- 'D' Box ✓ _ Type Filter Material 4,40o •Depth Filter Material Xe---------------------�-•-------- .. s Distance to nearest: Well --- --- Foundation - Property Line - -- SEEPAGE PIT Depth _Cg______-- _____ DiameterNo � Number -----�--------r----- Rock Filled Yes�i ' Water Table Depth ------�47------------------•------------Rock Size _ Distance to nearest: Well _- -----------------------Foundation __�----- Prop. Line/`-_2_....-.-• 4- REPAIR/ADDITION(Prey. Sanitation Permit# -------- ----------------------------------- Date ----------------------------------) 14 SepticTank (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------ ------ Disposal Field (Specify Requirements) ----------- --------------------------------------------------•--------------- --------------- ------------------------- - ------------------------------------------- ------------------------------------------- ------------------------------- (Draw 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 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 -----------------?- 'on ------ ---- ---------------•• ------ Owner By --- +� -------------------------- Title - -- -- ---- - -- Q7~y---------------------------- (If owner) FOR DEPART ENT USE ONLY APPLICATIdN ACCEPTED BY - -------- _ DATE -, ------ --- ------- BUILDING PERMIT ISSUED ------- -------------------------------------- -----------------DATE _._------------------------ ---------------- ADDITIONAL COMMENTS - ---------------------- -----------------------=--------------------------- ------------------------------------------------- ------------------------------------------------------------------------------------------------------------- -------------------- ------------------------------- - ------------------------------ t;;73---------------------------------------------------------- ------ - --Final Inspection by - -- - ---- Date - - ------------------- ------ ---------- mk SAN JOUll�-_, LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M , t