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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - Permit No. - ---- ---- -- •- (Complete in Triplicate) _ -------- �Z 3- Year 73 --- -----"- Date Issued --- J----------- - -------------------------------------------------------- Application ----------------------- -- This Permit Expires 1 Year Fram 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: --_� y. f R' > _ ------.-CENSUS TRACT ----- 7.57------ R 7- JOB ADDRESS/LOCA710N ._.-- --- --- +' # Phone ------------------------------- Owner's Name -- ----- ----------- Q-H-1 � J ' �� --------- ----- L1 IgRS)-------------- city --- Address -------- -----�7� �= -- ------ ------�'-- - ---- ------------------------- I - -------------------•---- Q� 7 °Phone --------------------------_-- '{ L;cense # -_ - Contractor s Name A_llU7i1 -_ - -------------------------- F *. Installation will server= Residence [�partment House❑ Commercial ❑Trailer Court ',❑eV t,y Motel ❑ Other -------------------------------------------- rooms ---- --------------------------------- -- _---Garbage Grinde - Lot Size -----��J�--- ' ------- Number of living units:----- Numb of bedrooms f - l It+ �, - Private `� '�---- ------ ----- - - ----------------- Water Supply: Public System and name:----------- - y ❑ Character of soil to a clepth of 3 feet: Sand' Si!#❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 1` Hardpan El Adobe ❑ F;II Material __ _ __ If yes, type -------------------- --- .- : {Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.l NEW INSTALLATION: [ {No septic tank or seepa [fit permitted if public e& is avaiiablewithin 200 feet,) �� 0. PACKAGE TREATMENT [ ] SEP71C.'TANK� Siz --- Liquid Depth ____--__--------------- ' -- ��_ T el 45'r-Material_ -r- No. Compartments ------•---------- i Capacity � 's` _--JyP i j r C ` 'f" Pro Line --__�----- ! i --�- ---------Fau-da#ion _-- -- P• -stance to 7�earest- Well _____-�-------- --- ------ --- � }v C LEACHING LINE [ No. of Lines-_-.�- ------------ Length of each line--..__ - ------ - ----- Total Length -----� •---------- jr 'D' Box -� Type Filter Materia _Depth FilterMaterial _______� ------=------- - i= ' f- ' -.a-.� Property Line - .---------•-- Distance to�neorest: Well --__ -__-__-=_�Fou.ndation _---- F � . J i SEEPAGE PIT ] p --_ Number-------- --------------- Rock Filled Yes ❑ No [ Depth ------1!-•----�-- }- Diameter --------; - �. I Water Table Depth --------------------- ----------------- Rock Size -G> . -- Distance to nearest: Well ----------------- ---------------------Foundation - -Prop. Line ---_----•----•------- ? ----- Date -------------------------- REPAIR/ADDITION{Prev. Sanitation Permit --------------------------------- --- _ _-- _ ___.-- �._ - _ T_� _,..-. Septic Tank (Specify Requirements) -------------- --------------- - _. �- Dis os 1�; w `' 1 -------------- al Field [Specify Requirements) ------------- s ----- ----- ---_ ---- --- - p ! i-- '� �! l ` E ------------ ------------------------------- ---= , -------- q , l ) [Draw exist-- and re --i--- ad'--------------------------=----------=------------------------ -------------'------...- clition on revers side)---' �. .�•x I hereby certify that l have prepared this application aad thar�,the work'will be done.in_.accorclance-With San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signator rtifies&thing:"I cert-fy tha i th erform work for which this permit is issued,'l shall not employ any person in such manner as to beam s j to W� � pensation laws of California."'OwnerSigned -- ----- -- ----- ------------ -------- ------------------ By -- --------- - Title ------ --- --------- ---------- ----------- (If other than owner) s FOR DEPARTMENT USE ONLY -#- = :DATE -- ----------- ----� ------ APPLICATION ACCEPTED BY --------L. '0---------- ----- -------------------- - - BUILDING_PERMI ISSU ---- - --DATE :- :_ : .`_-=::-=_. : - :: _ ADDITIONAL COMMENTS ---- g - .----_;_, ----- ---------- ---------- Finallnspec ----- --------Date ---- _ _ ------- - ---- --' - - SAN JOAQUIN LOCAL HEALTH DISTRICT r r N o 1.'68 Rev. 5M