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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: _73`-77-y" --------------------------------------------------------- (Complete in Triplicate) S'73 This Permit Expires 1 Year from Date Issued Date Issue __ .-'�____-.___-.. --------------------- ------------------------------------ I 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 __ v�"rd1____-"_ '" � �-=-J' ''"�` ` ENSUS TRACT _---=3 /---- ----- t -07 -- `-------------------------------------------------- -- Phone -- -- ------------------------ ------ �I Owner's Name ___ __�� """--""""' ' Address ---------- j"rcr City ---------------------------------------------------------------------------- Contractor's Name ----- --- --------.License # ------------------------ Phone ------------------------------ ._ " ---- --------- ----------- Installation will serve: Residence (Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other -------------------------------------------- Nu mber of living units:---- Number of bedrooms --3------Garbage Grinder .__`— -- Lot Size ------0-t -'------•-•----- Water Supply: Public System and name ------------ �------------------- ---------------------------------------------------------- ___--Private Character of soil to a depth of 3 feet: Sand'[] Silt❑ Clay ❑ Peat❑ Sandy Loam`CA Clay Loam ❑ Hardpan ❑ Adobe '❑ Fill 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.) NEW INSTALLATION: {No septic tank or seepage pit permitted if /public sewer is available within 200 feet,) SEPTIC TANK'( Size----� - ------------ -------- Liquid Depth --T/� `�/ il� PACKAGE TREATMENT [ ] ,p - Material___'=-4? ` . Compartments -._.__ Capacity ---��r--- i Type - ------ MiNor Distance to nearest: Well ------__ Fo LEACHING LINE No. of Lines -------"-------- ------ undation __--�Q----_-"_""-- Prop. Line ___ ---:------- 1 Length of each line-------- ------------- Total Length`.-_ _ ------------•--— [ ] 9 +? 'D' Box ------------ Type Filter Material ---- _____---Depth filter Material ______ __ ________ Distance to nearest: Well --------56--------- Foundation --------/---------- ----- Property Line -- -•- ----- SEEPAGE PIT [ ] Depth Diameter --------------- Number ---------------------------- Rock Filled Yes E] No ---------- Y❑ ' Water Table Depth ----''------- -------------- ----------.Rock Size ----------------------- I Foundation ------------------- ProLine ---------------------- Distance to nearest: Well ____- '_----- -- REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------- --------- - -- Date --- -- �f Septic Tank (Specify Requirements) -------------------------- =------------------------------------------- t ------- Septic ` 5 . Disposal Field (ppecify Requirements)- ________--__-___-_ _ � � �-'_ G- ---------- - �-----------------`---- -------�-f- ----- .Ad .----- --------------------------------------------- ------- ----- -------- --------------------------- {Draw existing and required addition on reverse,_side) I hereby certify that I have prepared this application and that the work will be done It accordance with San Joaquin r County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Loyal Health District. ome owner or licen- . sed agents signatur e,ifies th ollowing: "I certify that in t e p rforma c of the ork f hick this permit is issued, I shall not employ any person in such manner as to become to Wor n's C pens i5 laws of California." Signed ----.�Jt� ,6� - = = = Owner ' ' t �.; .. �� ------ Ti#le ---------- ----- -----"„-------- --------- BY ----------- ------------- --------------------------- ---------- -------------- - (If other than owner) OR DEPARTMENT USE ONLY _ APPLICATION ACCEPTED BY -------- �” DATE J BUILDING PERMIT ISSUED -----------.------------ -------------- DAT --- - ---- --- ----- ADDITIONALCOMMENTS ------------------------------------ ---------------------------------------------------- -------------------- ------------ --------------------------------------------------------------------- ------ -- -----=----- ------------------------------------------------- --------------------------------- - - ,F-- Date ------ -�-��-----�-5--• -Final Inspection tr�_ `_--�-��- --- '-- - � ----•-- - •---------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M