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FSR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. - ------------------ --------------------------- i 1 9 (Complete in Triplicate) U 72 -------------- -Date Issued ---------------------- �$ , This Permit Expires 1 Year From Date Issued /q 3—3-7 0 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: - �• o CENSUS TRACT ---- -------------------- OB ADDRESS/LOC T ON _ ��- ---- -- ---------- -- � - a I Owner's Name --- d- o.'A:-: ----------------- - ---------------Phone �a-`�------.! l 11 p �,Av y c� (�` City _[7!-� Q/ -------------------------- _______ _ _____________ -- c__ ' Address ---/- �- - �-� -- - ------� ---�-- -------------------------- -------- --------- ---------- ----- � / ��_,.._�?._ , I Contractor's Name _ d-.- 1 - License # c - _ � Phone Installation will serve: Residence ® Apartment House❑ Commercial ❑Trailer Court ',❑ Motel ❑Other ------------------------------------------- Number of living units:-----/r----- Number of bedrooms _4------Garba-ge Grinder ------------ Lot Size Private � Water Supply: Public System and name ------------------- ---------- •------- --------- --------- "-"-- ---- ----------------------------------------- Character of soil to a depth of 3 feet: Sand'R Silt❑ Clay ❑ Peat El Sandy Loam ❑ Clay Loam [I Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- l (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) NEW 1NSTAELATION: (No septic tank or seepage pit permitted if public sewer is available within 200feet,) � PACKAGE TREATMENT ''[ ] SEPTIC TANK:( ] size------- _3�- -c`�-_-- - - --- -- Liquid Depth - ----------------- __-_ .__.ts _ ------"-•-•- Capacity /__��------- No.Type �'�--- --- Materia!_�t�r. - ---- � /Com partmen --•-! f , Distance to nearest: Well -------cam----- ---- ----------Foundation --1-6------------- Prop. Line ----____-�-----"-•-=- ---" -- Tota! Length :-"-- ------------ Length of each line-------! -- g ------------------- �. t LEACHING LINE [ } No. of Lines _____ ____ ff - T.f� Depth Filter Material ----/P------------------------------ 'D' Box ----�-"_ --- Type Filter Material -------------- ----- p l t�� ---- SEEPAGE f 0 Property Line -------------- Distance to nearest: Well ___________________"" -- Foundation _-__ p �Y - Diameter __ Number ------------ --------------- ❑ I ` SEEPAGE PIT. [ ] Depth ------- ----- ----•-•- { -------------- Rock Filled Yes o Water Table Depth Rack Size ________________________ --r p - Distance to nearest: Well ---------------_------------------------Foundation ------------------- Prop. Line ----------------- EDate -----------------------------------) REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- ' 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 t 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 Workm s Compensation laws of California." Signed .. _______"_m--- Owner - --- ------------- - ---- ------------------ ------------------ (If - - Title ---- --------------------------- s (If other than owner) FOR RTMENT USE ONLY t APPLICATION ACCEPTED BY __._ ------ c_-- - --- --------2 -------------------------- DATErr� --------------- BUILDING PERMIT ISSUED.----- --- ----- DATE ADDITIONAL COMMENTS __._ -___ _ ------------------------------------ ----------- ---- ------------- ------------------ ---------------- - - - ------ ----- ------------ ----- -- ------- ----- --- --- ---- -------------- ----------- Final Inspection b SAN JOAQU C HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M -