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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. 73-16-11 (Complete in Triplicate) --- ------------------------------------------------ This Permit Expires 1 Year From Date Issued Date Issued2.. 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. 1549 and existing Rules and.Regulation/s: JOB ADDRESS/LOCATION.-/ s. 917---------5---------------- /_1r/Lc ---± - ENSUS TRACT _. '. -_------- Owner's Name -----------✓_._-------.� �--------------------------------------------------� ----•-------------------Phone ----------':------------------------- Addressf-------.- f ---------------------------------- ------------ City ----`��--�---ICJ - Contractor's Name __.___ ._ --------License # Phone3-9"_1 , Installation will serve: Residence ❑ Apartment House-[] Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number of living units:___/------ Number of bedrooms ______Garbage Grinder ------------ Lot Size ____._-___________________________________ Water Supply: Public System and name -----------------------------------------------------------------------------•-----------------•---------------Private Character of soil to a depth of 3 feet: Sand'[ Silt❑ Clay ❑ Peat❑. Sandy Loam V Clay Loam ❑ Hardpan E] Adobe ❑ Fill Material ----- ------ If yes,type ______________________ ____ f (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 p t per'Mitted if public sewer is avail a within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ I / /Size__________________-__._____._____------ _ __ Liquid Depth ___.._--------------------- Capacity ""._________,___- Capacity -------------------- Type -- - �----= Material---------------------- Compartments ------------- -------- f Distance to nearest: Well ____ ________________________;--____Foundation ___ ___ ____________ Prop. Line _____:-f;:________._._ LEACHING LINE, [ ] No. of Lines _._____________________ length of each line------------_--------. .___ Total Length _---______-i_ ------------ ------------ ___________ { Box .----------- Type Filter terial -�-_---Depth Filter at rial --------------------------------------------- 'D' Distance to nearest: Well ______ _________________ Foundation-- --_ Property Line _-___�___________._____ { SEEPAGE PIT [ ] Depth -------------------- Diamete ---------------- Number _._______.._.-.-`_ -__ ___ Rock Filled Yes ❑ No i❑ Water Table Depth.,: : --------- -------Rock Size -- -------------------- Distance to nearest: Well _________ _____________________________Foundatio Prop. Line ____......______.___.. 1 REPAIR/ADDITION(Prev. Sanitation Permit# ---------____1-_---------------------'--- Date ------------- ---- = ___.__.__________] 11 Septic Tank (Specify Requirements) ----- ---------------------------------------------------------------- ------------------ -- -----------------..... Disposal Field (Specify Requirements) ------- 2-47----------- . �---------------------------------------- ------------------------- ------- ------- - - -----------------------------------•---------------- --------------------------- ------- (Draw existing affil required addition on reverse side) I hereby certify that I have prepared this application and that' the work wilt 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 subject Wo kman's Compensation laws of California." Signed ------------- ------ ---------------- Owner By ---------------------------------------------- -------------------- - --------------- Title ------ --------------------------- - -- ------------ -'-------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . .-0---------------------------------------------------------------------------- DATE _ _ _ --- BUILDING PERMIT ISSUED -----------------------------------—_-_-__-----r.--__ .__:_:.�_ --- ------:.-:-.:_DATE........__/------- ADDITIONALCOMWENTS --------- - ----------------------- --------------------------------------------------------------------------------------- ---------------------- -------------------- -------- ---- ---------------------------------------------- ----------------------------------------------- -- - ---•--------------------------------- ------------------------------- -- ------------------- _. ,------ - --------- --------- -- - -- --- - ---- - __ ` Final Insp ------------------------------ SAN -------------------------- f � SAN JOAQUIN LOCA!_ HEALTH DISTRICT E. H. 9 1-'66 Rev. 5M