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t FOR OFFICE L15E: : APPLICATION FOR SANITATION PERMIT , ..............................................-------F (Complete in Triplicate) Permit No. 73. ........ r ............ -..7 - ........................................................ 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: JOB ADDRESS/LOCATION —...-` t_ m?n._ ...CENSUS TRACT ------------------------ Owner's Name ........ .....1.1/�!.I~.0 ''' ................ ........---....... -- - -- ---Phone .................................... Address ........ ` _.. ---....--/.�----------------- ----------------------------- City .......... ..................----......... ............................. Contractor's Name j ------.License Phone 6 1----- Installation r will serve: Residence ❑ Apartment House❑ Commercialrailer Court C] w Motel ❑ Other ....--------------------- ------ •- Numbercof living units:............ Number of bedrooms .__._.-_-...Garbage Grinder ......... Lot Size -•••••••-- t Water Supply: Public System and name .........................---.................................-.-...._..-------------•-••----._....-----------.Private] Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe [ Fill Material ..... ...... If yes, type ............................ CP (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 'J1 i NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ] ] SEPTIC TANK Size..--------- _ .. .. .. Liquid Depth -57- . . . ....... Capacity Type 31.%4L- Material. - No. Compartments _ _ l I Distance to nearest: Well . ...��`. ----- ------Foundation ../0C"1& ....._ Prop. Line _ .'. Z LEACHING LINE [ ] No, of Lines -- Length of each line ..I1 .._. .. Total Length ......... 'D' Box —A ...._ Type Filter Material __...__ epth Filter Material ...��.................................... r i Distance to nearest: Well ..... ire`_.._. Foundation J.'!;�.........— Property Line SEEPAGE PIT { ] Depth . Ass-- .--... Diameter .-- ..... Number .... .............. Rock Filled Yes No C r ` � P! Water Table Depth -------'�'��.. •-�------------- -------Rock Size _....f.. !<•.....----------- Distance to nearest: Well ..___._.if _ ..................Foundation .___ �.. ._.... Prop. Line _�..._ .......... REPAIR/ADDITION(Prev. Sanitation Permit# ........ ---•.-------- -------------- Date ------------------ --------- ...... Septic Tank (Specify Requirements) .. _..... ......... - -------- --------=------• .......... -------------------- --._...----.. ........................ Disposal Field (Specify Requirements) ------------------------------------------------------- ......----...._...---------.......................-.......... ................ ......... . . ............ .........----.---------------..._...---- --- --- ............... ...................-................... (Draw existing and required addition on reverse side) I hereby certify that I 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. Horne owner or liceew 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 to War an's Compensation laws of California." Signed .:._ Owner _ By .... ............................... .Title .. . (if other than owner) FOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY — ! _- - --- ------- _-_.--- DATE . .3............... BUILDING PERMIT ISSUED ....- `_ .._. . .. _ ................................. :._ ....DATE _.. -.--.-. .._ ADDITIONAL COMMENTS .. ... . ..... ... ..•. ....................... ................/-... ---- -- - --- -- ---------------- . ------- -----•---- ------------------------------- i ..................................... . ... .. . .. .......................................•-------------•- --.-.:_ ..-.------.-.._....�- / Final Ins ection b ---- ----------------------•---...._... ..._.Date _... ._ --- -- [ P Yl�� -------------- ? SAN JOAQUIN LOCAL HEALTH DISTRICT 71773 H