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APPLICATION 1OR SANITATION PERMIT _ i FOR OFFICE USE: Permit No. --Z- -��a, r ;., ' (Comple"te in Triplicate) a2 _/o-73 Qate Issued ----•------------- i /f. i This-permit Expires 1 Year From Date issued 4 :u q County Ordinance No. 549 and existing Rules and Regulations- Application anon is hereby made to the San .loa uin Local Health District for a permit to construct and �ristalk the work stem Apphc described. This application is made-in compliance � Y CENSUS TRACT .----.------ ---•---- 10VA nw�_ JOB ADDRESS/LOC T N ------- ----- -- Pho --------------.-------- -------------' ------ --------� ------- t� Owner's Name 2= ------ eel ---- --- CffY f Address _._ Phone = ---.License ---- --.--- ----- - Contractor's Name ------------------ Resi�ienceartment Hous e0 Commercial [ Trailer Court ; installation will serve: - - ----- _ - Motel C]Other -------------------------------------------- 11%. ---- ----- --------------- - ---- -- _ - --_______:.Garbage Grinder_=.----�--=, Lot Size - Number of .living units C_------- Number'ofYbedrooms� Private r -------------- -------'-----------------"--'------------------ Public System and name --------------------- --- - f Water Supply: Y l� peat❑ Sandy Loam Clay Loom ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt:[] Clay ❑ t Fill Material ------------ if Yes,type ---------------------------- Hardpan ❑ Adobe ❑ �- buildings, etc. must be placed on reverse side.1 (Plot plan,_showing,size4 of lot, location of�system in relafii n to wellsi _ - •� NEW INSTALLATION: (No septic tank or'seepage pit permitted if public sewer is available within 200 feet,) Size. -------- Liquid Depth ------------------=.------ Size -- t PACKAGE TREATMENT [-] SEPTIC TANK:[ ] ------------ t" Ca acit Type Material " _ No. Compartments ---------------------• � p Y .-. . .�', Foundation ---------------------- Prop. Line --------- pp .Distance to,*nearest: Well` _- .........."- -- C4 IN t :�, Total Length ------ Length of each line---------------------- [ ] No. of Lines--------------- "D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------------•------ L -------------- Property Line ----------------------•- Distance to nearest: Well ------------------ Foundation SEEPAGE PIT [ I Depth Diameter ---------------- Number ---------------- Rock Filled Yes ❑ No �--- P ------------------------------------------------ --------------------------------- ------------Rock Size -------- ----------------------- --------- Table Depth Foundation - Prop. Line -------- Distance Distance to nearest: Well --------------------------- ----------- � e _ IdPA1R/ADDITION(Prev. Sanitafii"on Permit# -----=-- ---=----=---------------------- ------------------------- iSeptic - - - iSeptic Tank (Specify Requirements) ------------- ____---------- • --- ---------------------------------------------- n - ---- - ---- Disposal Field (Specify Requirements) ----- -{.�- a ----------r--=- g q u ---------- ----------- -------- = -------------------------------------------------------- --------------------------- and that addition on reverse side) ---------- --- - ---------- - ---- - - --- --- (Draw existin and required I Ilhereby certify that I have prepared this application a at 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: arson in such manner "I certify that in the performance of the work for which this permit is issued, I shall not employ any p 4 as to become subject to Workman's Compensation laws of California." Silgned •-?//r�''0 --------------- - Owner -------- - ---------------------- --------------------------------------- --------- - Title --------- ------- - ------ -------- ------- -- { (lf other than owner) k[ FOR DEPARTMENT USE ONLY # DATE _ .�_ _� ----------- --- --- i APPLICATION ACCEPTED BY -- ------ -- - -- DATE ------------------------- --------------- BUILDING PERMIT ISSUED --------------------- ---- ADDITIONAL COMMENTS ------,'-------------------------- ----------------------- - ------ ----- - -------------------------------------------------------------- ---------- ADDITIONAL ----------------------------- _ - ------------- ---------------------- n ___________________A___..___k.____.___.--___.______-_______.____...--_-__ - ---- ----------- .------- i___________________"_-__-__- _._ _. -J Date -- ---------------- --- Final Inspection by: ___:__ -- � = SAN ,JOAQUIN LOCAL HEALTH DISTRICT X , E. H. 9 1-'68 Rev. 5M