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FOR OFFICE USE: APPLICATION POP. SANITATION PERMIT Permit No. ------.•--- ---- --- ---- ----- --"�-:� r �.��--- ,Complete in Triplicate} , ----------- -------------------- Date Issued -f7-73 This Permit Expires 1 Year From Date Issued compliance strict install the Application is hereby teoe in Local Health Di descred. This application pplo ismad �in wih County Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION `` +� : ----- �Yd.S` -------- --- ---- ---CENSUS TRACT -------------------------- Owner's Name _-.1--------------------------------------------------m-------------------Phone -- --------------- ----------------- -------------------- City _ -------------------- -------------------------------- ---------- Address ------------------- ----- Contractor's Name - ._ 4_ic: ---=------------------------ =License #�rjS.�_�---- Phone Installation will serve: Residence artment House❑ Commercial []Trailer Court "D �R Motel ❑Other -------------------------------------------- f + � G'�------------ Number of of living units:________1_ Number of bedrooms " =--•Garbage Grinder Lot Sizef Water Supply: Public System and name - - ---- ----I------------------------------ Private ❑ Pp Y� Y ---- �--------- i - Character of soil to a depth of 3 feet: Sand':E-1 k Silt❑ Cla�illlm Peat❑ Sandy Loam ❑ Clay Lodm:❑ 4,`t• Adobe aterial ------------ If Yes, type ---------------------------- Hardpan ❑ (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 pit permitted if public is available within 200 feet,) SEPTIC TANK; 'f Size-----------------?`----------------- ---------- Liquid Depth -------------------------= PACKAGE TREATMENT [ ] [ ] �.. f Capacit Material -------------------- No. Compartments ----------------• Y -------------------- Type ------ Distance to nearest: Well ------------ ------------------ Foundation ---------------------- Prop. Line ------_--- Len ih of=each--line---------------------------- Total Length ----------------•------------ LEACHING LINE [ ] No. of Lines g 'D' Box ------------ Type Filter Material-----------------_`Depth Filter Material ------------------------------•- J Distance to nearest: Well --------------------- Foundation ------------------- Property Line --------------- SEEPAGE PIT [ ] p - Diameter ----------- ---- Number ---------------------- - Rock Filled Yes ❑ No i❑ _ =- -_.-Roc Size-=_ :7 :-:---=--------- *-Water-Table Depth.._i-'"--- --------------- = Distance to nearest: Well ----------------------------------------Foundation -------------------#- Prop. Line ------------------ - i # f F REPAIR/ADDITION(Prev. Sanitation Permit# ------------ -- ------------------ to + Septic Tank (Specify Requirements) ------ .--- I --- Disposdi Field (Specify Requirements) -------------------------------•----------------------------------------------------------I------- r r ------------------- -------------------- ---�------------------------------------------------------------------------------------------------ ---------------- -t I --------- ------------------------ ----------------------- - t ____------ - I (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 I 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 to Workman's Compensation laws of California." Signed --------------------- Owner _ ____ _________ _________-________F__---. -____-__ t�Z Title __. r (If oth an owner] , EPARTMENT USE ONLY APPLICATION ACCEPTED BY _ e - DATE --- L�= j`?= ��-------------- - ----= �;r DATE ------ ---------- -------- ----------- i BUILDING PERMIT ISSUED - -- - - - - - --- --- ------ ------------------------------ -,-.------------- ADDITIONAL COMMENTS ------ - - eft ----- ---- --- ----------------------------------------- - -- _-_._--- ------ --- -F - --- -------- -._.Date - �''� =� _�. Final Inspection by: __--- -- --- - •---- -----�-------- SAN JOAQUIN LOCAL HEALTH DISTRICT rti � F- H. 9 1-'b8 Rev. 5