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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ��-` -7�• �i ----------------- ---"" --"" ---" ---------------------- (Complete in Triplicate) �/ ----------------------- -- --------- p Date Issued �`--1`�-73 ---------=-------- - -------- ----------------------------------------------- This Permit Expires 1 Year From Date Issued Application 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: 1 JOB ADDRESS/LOCATION __� r-1�----- a �� _---------- ---"----------------- -CENSUS TRACT _------------------------ --------------------- Phone -� -, ------ Owner's Name _. 2--- Phone --------•-- City ' f Address �- -- - - - �---- � �/_�_ �------��-�-y---- - -- �- - ------------------------------ ------ - � 1_ C? �� - Phone - - Contractor's Name . - -1� -------- License #� - --. Installation will serve: Residence KApartment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other -------------------------------------------- Y Number of living units:------- Number of bedrooms __3-------Garbage Grinder --__"--__ _ Lot Size - ------- --------•-- Private IR ; Water Supply: Public System and name ____________ - - - --------' ---------" --"-- -- ------------------ I ❑ y Peat Sand Loam Clay Loam 1] Character of soil to a depth of 3 feet. Sand Silt Clay ❑ ❑ Y ❑ Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- (Plot plan, showing size of lot, io#at;on of system in relation to wells, buildings, etc. most be placed on reverse side.) NEW INSTALLATION: (No septic C TANK'tank or seepage pit permitted if public sewer is available within 200 feet,) SEPTI0 Size------------------------------------------------ Liquid Depth --------------------------- �+ PACKAGE TREATMENT [ ] I [ a Ca acit Type Material------------------ - No. Compartments ------.--------•-_---- PY - --------------- Distance to nearest: Wel[ _________________________ _____ ----Foundotio ---------------------- Prop. Line ------------------•-- Len th of ch line------- ----- ----------- Total Length .-----------•------- LEACHING LINE [ a No. of Lines ___________________ __ g a Det Filter Material D' Box "----- Type Filter Material __ __ _________ P Distance to nearest: Well _.______________ _ Foundatio Property Line SEEPAGE PIT [ ] Depth -------------------- Diameter ----- ---------- Number ---------------- Rock Filled Yes ❑ No ❑ �— Water Table Depth Rock Size I undation Prop. Line Distance to nearest: Well ____"____ ______ ________.------ I Date - ) REPAIR/ADDITION(Prev. Sanitation Permit# -------- -- ----------------------------- Septic ---------------- Septic Tank (Specify Requirements) -------------------- ------------"-------`----------- Disposal Field (Specify Requirements) Z;7 -------------�— �4PPR ----------------------- (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, I shall not employ any person in such manner as to become ubject o War an's Compensation laws of California." I ---------------- Owner Signed - - ----- --------- ------------ -- --- ---- ------------ - - ------------------- Title ------------ ---------------------------------------------------------"- (I other than owner.) FOR DEPARTMENT USE ONLY _ E ------- ----- � APPLICATION ACCEPTED BY ....... -`-- --- - ---------- ------------------- --------- DAT---DATE ------- --------- --------"----------•--• BUILDING PERMIT ISSUED ------- -' '------------------------------------------------------------------------ ADDITIONAL COMMENTS ----------r-- - ------ - - ---------------------------------------------- ------------- --- - --------------- -------------- � ---- --- --- _ ------------------------------I------------------- �'/ e. -------------------------------- - � ----- ---- ------------.----------- - - ---------- ---- - -,--- ------ Date ----- ------ Final y_ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M