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OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: ----------- (Complete in Triplicate} / -73 Date issued -.------ P :FOR ---------------- - ------------- - This Permit Expires 1 Year From Date issued Application is hereby made to the San Joaquin mplianceLocal wi hHealth CounDistrict Ordinance No. 549 and existing Rulesinstall ndthe Regulations: Pp described. This application is made in comp CENSUS TRACT + ` --------------------------- JOB ADDRESS/LOCATION . l_1- q �� Phone ..� Owner's Name ----------- IViNQN_ Address -------------------------------------------------- --- ----- --------=------ --- -------- ---+- -----•--- ----- ----------- . Phone ----------------- ------.License # Contractor's Name --- ---- ------ installation will serve: Residence[(partment House Commercial ❑Trailer Court '❑ ? t -� Mote! [3 other ---- ----- ----- -------------------- --3------Garbage Grinder Lot Size Number of living units:..-..---- Number of bedrooms ------Private @� - ---- - ---------------------- - - --------------------------------------------------- ------ - - - Water Supply: Public System and name -------- ---------------------------- I peat C] Sandy Loam ❑ Clay Loam.0 Character of soil to a depth of 3 feet: Sand'[] Silt❑ Gay ❑ -- !f yes, type -------------------------- Hardpan E] Adobe' Fill Material __--____-- -� t buildings, etc. must be placed on reverse side.) (Plot plan, showing size of lot, location of system in relation to wells, I +t ermined if public sewer is available within 200 feet,) � � NEW INSTALLATION: (No septictankor seepage p p Liquid Depth __ Axl ------- - PACKAGE TREATMENT j I SEPTIC TANK,' Size.F-` �s Wlij-A------- __ , C(`Q-�---- No. Compartments ------`�- --•---------- t _/ W. Capacity _1Q^+�::°---- Type - ' - Mater+al.c,(�Y►- -Foundation ----I-�------------ Prop. Line , . _-. Distance to nearest: Well ---.-� --- --- 9-70-. c� �0 Total Length ---- k LEACHING LINE I l No. of Lines Length of each line-_---.---- - ,- ---------------- ---- - ,� - .De th Filter Material ___----�---------------[-r----•-----•--'--'- D' Box 1f5----- Type Filter Material p �� Property Line --_-`� r Foundation -- p ----- -------- -- ' Distance to nearest: Well ----- -- ----------- Rock Filled Yes ❑ No C SEEPAGE Depth --------------- Diameter -..--------- --• Number ----- ----- ----- --- ,. _� [ ] p I . Rock Size -------------------------------- Water ------ ---- -----------•-------Water Table Depth ------------------------- \ � -------------- ----Foundation -------------------- Prop. Line -----•-------------•-- Distance to nearest: Well --------------- - iDate -------------- 1 REPAIR/ADDITION(Prev. San+tati on ermi - - -------------- Septic Tank (Specify Requirements) ------------------- ------ ------------------- -----•--------- } ------------------------------------ Disposal Field (Specify Requirements] ------------------------------' " ---- ------.------ -------------------------------------------------- ----- -------------- _ ` ------------------------------- ----------- ------------ --- ------ -- ----- - (Draw existing and required addition on reverse side) i that I have prepared this application and that the work will be done in accordance with Sa'n' Joaquin I hereby certify j ..Count Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Hom�wn� or liters• Y sed agents signature certifies the following: person in such manner "1 certify that in the performance of the work for which of Cpermit is alifornia.„ssued, I shall not employ any en ati.on la as to become subject to Workm Owner Signed,, ------ + rr � ------ Title -- ------------------ ------ ---- By ---------- -�----------------- ----- ----- --- - d i (If other than own ----er) �. I FOR DEPARTME T USE ONLY • DATE ------ --------- ---•- ----------------- � ---- -------- ------DAT APPLICATION ACCEPTED BY ------------------------- --- ---- ----- - -- - --------------- --- - - --- -----°----- - --------- BUlLD1NGPERMIT ISSUED ------ -------------------------------- - ---- ----- ------ ---- ----- ----- ----- ----------------- -----•------- ( ADDITIONAL COMMENTS °----- __ ---- --------- __ _ I -- = ----- -- - ------------- ------------ -------------- -- --------------------------- - ------------ _ ---Date � 6' � Final Inspection by: -------------------------------------------------------------- ------- ------ ------ -------------------------------------- --------- ----- SAN JOAQUIN LOCAL HEALTH TRlCT Q72) c W 0 1-'68 Rev. 5M _