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FOR OFFICE USI:: . APPLICATION FOR SANITATION PERMIT ` ....................................................... {Complete In Triplicate) Permit No7.2 {P 27 . .... .. .... ...... ................................. .• . • . .......... ThIs PprrnitExpires 1,)Fear From Date Issued Application Is-hereby made_to,the Son Joaquin Local Health District for a permit.-t"onstruct-and,install the work herein described. This application Is made In compliance•with'County Ordinance No..549 and existing_Rutes and Regulationse. JOB ADDRESS/LOCA ON ...11_4;1M..._.�..... ............................. .....CENSUS TRACT .......................... Owner's Name £ $ .�!` ................................... .....................................Phone' Addre ...... . .__._ .PAZ.....................................City ............... ........................... Contractor's Name` ~- ', .. ,�jf.__ 1�. .:__ .................LicensePhone _ '. Installation will serve, a dance rtment House t] Commercial❑Trailer Court 0 Motel❑Other........................... ............... { Number of:living units=-•=--•--•--- Number of bedrooms .....Garbage Grinder ............ Lot Size .-C& ...........`---�3 Water Supply: Public Systim and name __...__ ....._•___........._...................._......._.............................. .. .Private Character of soil to aidepth of S feet: Sand❑ Slit❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay loam ❑ Hardpan❑ Adobe Fill Material ............If yet,type............... ............ (Plot plan, showing size of lot, location of system In relation to wells, buildings, etc. must be placed an reverse %lde.l NEW INSTALLATIONS (Noptic tank or seepage pit permitted if public sewer is available within 200 feet,) . PACKAGE TREATMENT SEPTIC TANK I Size.... ....__: __........ Y.- •_•-_-- Liquid Depth y.................--••--•• r ' l Capacifyl+ �. ype .. Material..... _._ No. Compartments .f2 ...._-.... j .------ :Prop. Line . tDistance to nearest: Wetl� .....&Z? .. Foundation .........:. .. LEACHING LINE No. of Lines - ... Length of each llne-11.0 r..3-vr-.___--_ Total Length . "D' Sox .I._...... Type Filter Matarlal .Depth Filter Waterlal ��...! Distance to nearest: Well ......................... Foundation . ................ Property Line ......... i SEEPAGE PITS Depth j........ Diameter _.. . �.". Number __. ..................... Rock Filled Yeses No Q fWater,Table Depth __1 v-d....................................Rock Sizex._..._...._.._-...._ Distance.to nearest:Well . 4::�..........................Foundation 1.O.-.._.... Prop. Line .. .. ._....-- REPAIR/ADDITION(Prev. Sanitation Permit �" `-` x •- -•--••-•--•-- - = �at9 .�...... ..-----••---••• Septic Tank ISpetify Requirements) ......... ......_ •------ . ._......----•--................._...... ':'� :»........_ . ... - - -- F Disposal Field (Specify Requirements) •-------•. ..................... . a T ._..........._......................__:.._....... r ...................................-••-................................................. ......—..................................................................................................... r* �......... .....................••-• --••-----•-........................_.................. (Draw existing ane required addition'an reverse tidal t 1 hereby certify thset�I have preps d this tt�plicatfon,and thot the wark w be dans in aceorelance with Sara Joaquin County Ordinances,'State Laws, and wand Regulallons of the San Joaquin Local Health District. Home owner or Ilcen. sed agents signature certifies the fallowing: "I certify that in the performanceiif the work fi r which this_permlt is fCsuetdj zholl not employ any person In such manner f� as to become sub(ect to Workman's-Compensation laws of Calffiarnla." k Signed ..L .. ..............•..................... = ,. Owner i By ............................................ ..._.._._._. ....................... - . Title,. .................................................................... , (if other than owner)' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ..................C-10............ ...---•......,.. DATE /.--/,x•-:77......'.:-: ------------- BUILDINGPERMIT ISSUED ...................•-=•----•-..-•-•------••--------• ---------•-- ----------- .................... __DATE _.--.._..........•••---=---.. __............ ADDITIONAL COMMENTS ----------- ............................................... .._.__......:.....-: ... : _ ........................................... ............•--......I.........----..... ... �` ._." _ ...._....... Final Inspection by . .�;':�.:��:a. =---... _.._. .. .....---.. ..,........................•-_.Date . -.,.. 4T 13 2h 1-68 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3M