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FOR OFFICE USE: 3 APPLICAT16N POR SANITATION PERMIT Permit No. .-_73��-�•-� ------------------------------------ - - /_/"`-----"------- (Complete in Triplicate) __. Date Issued ----- p ---- _ Y _ This Permit Ex fires 11 Year From Date Issued A lication is hereby made to the S�n Joaquin Local Health District for a permit to construct and install the work herein PP described. This application �s made JOB compliance with County Ordinance No. 549 and existing Rules and Regulations yf�- LCI- ------- --------- -------- ----CENSUS TRACT -------- ..------ JOS ADDRESS/LOCATIO ---��---{''- - Phone C �'2u � ------------------- Owner's Name c - /fs•' - - City ---------------------------=-------•--- Address � f" ' s- ------- - ` - __.License #4- 1_V,_7 Phone -' Contractor's Name __��/�'-�•�'"��=�- -�� '�-'�� Installation will serve: Residence ❑Apartment House'❑ Commercial ❑Trailer Court ',❑ Motel ❑Other ----- D-PlFIX--'-----------•--- r Number of living units:... -- Number of bedrooms __ ._Garbage Grinder ------------ Lot Size - --------- Private --------------- --- - Water Supply: Public System an name _____._________________-____- --- --------------------------- - 411 [_1 y Clay Loam ❑ Character of soil to a depth of 3 feet: Sand'❑ . Silt❑ Clay ❑ Peat Sand Loam ❑ Y Hardpan ❑ Adobe or Fill Material -.___._____ If es,typ (Plot plan, showing size offl lot, location of system in relation to wells, buildings, .etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pili permitted if public sewer is available within 200 feet,) SEPTIC TANK; Size------------------------------------------------ Liquid Depth ------------------- ------ PACKAGE TRE, [ [ Capacity ---------------- Type -------------------- Material----------- ---------- No. Compartments ------•--- Distance to nearest: Wel[ ----------------------------------------------------- Foundation ---------------------- Prop. Line --------------•....... Total Length ----------- --•---•---•----- LEACHING LINE,. [ ] No, ofl-ines ------------------------ Length of each line------------------------ �fiClST, 'D'. Boxy--'____----- Type Filter Material --------------------Depth Filter Material _.- --------------------------------- t - --- ------------- --- ______ Foundation -------------------- Property Line 4 Distance to _nearest: We ------------------ .� Diameter '----- Number _------------------------- Rock Filled Yes No 0SEEPAGE PIT [ ]. Depth ___ 5 ,--- - _ r � y 0-- Rock Size 4K esti Water Table Depth ---------- � -of- X . _Foundation __.f0---------- Prop. Line ---- ------------•-- Distance to nearest: Well -----•-- �l Date -------•--------•-----------------) REPAIR/ADDITION(Preva Sanitation Permit# --------------------- Septic Tank (Specify Requirem6nts) ------------------------------------------------------------ 4. - .- Disposal Field (Specify Requirments) -- -� f ' r �-� t - � ----- - --- --- ------------- ------------ (Draw existing and required addition an reverse si d e) i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin f 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 performanck of the work for which this permi is issued, I shad not employ any person in such manner as to become ct to Wo ma ' Com ensation laws of California." Owner Signed _-_-- ---- itle --------------- By - --------------------------------------- -- (if other than own FOR DEPARTMENT USE ONLY r ✓ APPLICATION ACCEPTED BY -___.__ _-_ _ ---- ------- DATE 7 BUILDING PERMIT ISSUED __ ----------------- -----------------------------------------=------------- DAT --- -----------------------�------------- ADDITIONAL COMMENTS --------- --------------------------------- ------------------_ ------ ---------- ---- -------- --- _ --- - --- --- ------- ------ ------ ---- ------------------------------ ------------- - ---- --------------------------------------------------- -- --- -- - --- -- _ - _ Date Final Inspection by: ------------/------ SAN OAQUIN LO AL HEALTH DISTRICT r u 0 1-'68 Rev. 5M