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w . FCR OFFICE USE: _ 1 - APPI,ICATION FOR SANITATION .................................................... ON PERMIT (Complete In Triplicate) Permit Nd. 76" !;-,7,3 ............... .....................•............ This Permit Expires 1 Year From Dote Issued Date issued - 7L Application is hereby made to the Son 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/LOCATION CENSUS TRACT Owner's Name ......_1 -.-I g / _ �` .. ......Phone .._ �G Address _........ R� .... City _. •----•-----•---------•----------- ` Contractor's Name •.. _ M .... •-•----------•--•---•--••-------•-----------------••--__--License ._ ...... ._ Phone Installation will serve: Residence Q Apartment House Commercial(]?raper Court 0 - Motel .• ❑Other........................... Number of living units ............ Number of bedrooms ------------Garbage Grinder .... Lot Size Water Supply: Public System and name ................... ..Private Q Character of soil to a depth of 3 feet: Sand Ej silt 0 Clay ❑ Peat❑ Sandy Loam p Clay Loam 0 Hardpan❑ Adobe 0 fill Material ............ If yes,type............... ............ "N (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 pitperml"d if public sewer is available within 200 feet,�� PACKAGE TREATMENT [ ] SEPTIC TANK[ �S,�sr�dv.............. 1-��✓d� Iquid�ep Capacity -------I.......__-.• Type ---_-----_-------_ Material...................... No. Compartments Distance'to nearest: Well ------------ ---••-.........._....Foundation --------•--•-•-•---• Prop• Line -•••-••--............. -LEACHING LINE -'- [ � No. of Lines ----------------- Length of each fine............................. Total length ............................ V Box.......... --- Type Filter Material ....................Depth Filter Materia) Distance,to nearest: Well ........................ Foundation ...................--... Property Line _........._...__. ...... SEEPAGE IT [ ) Depth ..............•----. Diameter Number ••--•-----..... ............................ Rock Filled Yea ❑ No Q Water Table Depth "' ` 4 ....Rock Size Distance to nearest: Well .--- -•----_-_----_-•-....f... _..Foundation ......... .......... Prop. Line ...................... REP R/ADDITION ev. Sanitation Permit# ♦ " ' ( -_.._._ Date __•.... s......... ...... Sep ' ark Requirements) ..►� fy q ) ............... �..... ... ..... Disposal Field: (Specify Requirements) Q -------•----------------••----- --------••-----•--•--- a,P ............. -----••-•---••---- 33-y X -5- . ( Draw existing-and required addition on reverse side) I hereby certify that 1 have prepared this 4plicotl6n grid .that the.worktwill be done In accordance with San Joaquin County Ordinances, State Laws, and Rules and Re'guieatlons of the Son Joaquin Local Health,Dlstdct. Horne owner or Ilcen- sed agents signature certifies the following- '1 ollowing:'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 suble Workman's Compenscitian IaV;s of Califaml€ " , Signe c -----------------------•--------��._ Owner • 1 - - -----• -+-----'---D--------- ----a-L - -• 44 (i#other than owner) + {. ------ _� ---------I.. R�DEPART ENT F ONLY ' APPLICATION ACCEPTED BY ..... .. f --•--------- ------- -----•---------- �_7_ DATE ------ ------------ BUILDING PERMIT ISSUED ............... DATE - ---------------------•- -•------------ ••--DITIONAL COMMENTS ------- ..--_... . - ....... -"---•-•. •..................... ...•---......-----.....---- - •-------- - - -- fi�al Inspection b .. P Y o' + 4 ....Date _. EH 13 2h 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT a 3M a