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FOR OFFICE-t-USE APPLICATION FOR SANITATION PERMIT Permit No.r. -------------------- ------'- - - --- ------ (Complete in Triplicate) 73 - - ----------------------------------------- --- This Permit Expires 1 Year From Date Issued 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: l � '� I______._CENSUS TRACT _ JOB ADDRESS/LOCATION .-------------- r C?!7_/� Tl # Owner's Name j`�_� �.J 'U f_+ f .------�? - ----- ----- Pftone . +-------- Address ,� , ��..,, ��JJ A - - Address - t � '� !fes- City .i1 - 1 rJ ---------.. Contractor's Name _Cr'_�f -------------------------------------License* pfd --- Phone ' -- Installation will serve: Residence T]Apartment House f:] Commercial :❑Trailer Court i❑ Motel ❑Other ---- -------------------------------•------- Number of living units ----- Number of bedrooms�---_-_-Garbage Grinder --------___ Lot Size ' -�� ` ------------ �; -- -- . -_�.- Private } Water-.Supply: Public System and name = w = = Character of soil to-a-depth of 3.feet:—Sand Peat❑ Sandy Loam ❑ Clay Loam.❑ r Hardpan-D-- Adobe-❑-T-Fil I-Material :--- -1f yes,type ------------------------ (Plot plan, showing size of lot, loca�t�ion of.systemin relation to wells, buildings, etc. must be -placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted-if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK;[ ------------- ---- -- Liquid Depth ------------------ Capacity -------------------- Type -------------------- M erial------------ �-=-- .-- No. Compartments ------ --------------- Distance to nearest: Well ----------------------------------Found on ---------.------------- Prop. Line --•.------ --:--- LEACHING LINE [.] No. of Lines __.__--_---------- ---- Length of ach line---- ---------------------- Total Length ____.__..------.--_--------_ 'D' Box ------------ Type Filter Material--------------------- epth Filter Material -------------------------------------------- Distance to nearest: Well _____________ _____---- Found tion Property Line. ________....._____._.... SEEPAGE PIT [ ] Depth -------------------- Diameter --------------- Nu ber __-____.___--_.-.-_--_--_- Rock Filled Yes ❑ No ❑ Water Table-Depth ------------ -- ------------------------ ------Rock Size -----=•'-------- ------------- Distance to nearest: Well -_ --------------------------- -- ---- undation _�---------------- Prop. Line -..._--_-__.__......__ REPAIR/ADDITION(Prev. Sanitation Permit# ----------- Date ----------------- _________________1 Septic Tank (Specify Requirements) ---------------- ------------- ------ ------ ------------------- --- -- -------------------- Disposal. Field (Specify Requirements) __,44 __---� -`'` ----- --- -------x:- ---------Y-'�• - / ------------------" --------------------"-------------------------"___'._________ ______ _ _ _______ ----------------------------------------------------------------------------------_________________________ (Draw existing and required addition on reverse side) I hereby certify that 1 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 subject I Work an"s Compensation laws of.California." Signed ----- -- ---- ----- ----- - -------------------------''--- ------------------------------- Owner _ Title --------- ---------- -- - ---- ------- --- ------------------------- -- - 11f other than owner) FOR DEPARTMENT USE ONLY --- D -- - -- APPLICATION ACCEPTED 'BY -- ----- -- --------------------- ---------------------------------- ----- DATE BUILDING PERMIT ISSUED --._ ------------- -- ----------------------------------------- ----- ` ---DATE --------------------•------------- ADDITIONAL COMMENTS ' { "A--- -- - --------- ----- �------------- -----------------------------------------------I----------- I _. __ -_- - } lf � __________________r-_._--..--_____ - ____--_.-- -_-___-----_-------__ --.--_- ----_ -____----._--------___-_---_________-_-__---.---------- -_---.___--__--._---_--__---_- ----- -- -- __-_____._-----..---_ --_---_--_ f-"______ _____ ------------------------ --- ____ __ - - _______ - _•Final Inspection b = z_ ��`� - -- -�-�2----------------------- Date • SAN JOAQUIN LOCAL HEALTH DISTRICT f I y. __ E. H. 9 1-'68 Rev. 5M