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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------------------------- Permit No. ._.77=_7�___ (Complete in Triplicate) ------------------------ ------------------------------- 54 This permit Expires 1 Year From Date Issued Date Issued __.__��y_7_. 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 1_f ------ `------------ -`-� -----------------CENSUS TRACT --��7` ----.-.----.---- Owner's Name ------- --------------------------------------------------------------------- ------- -------Phone --...- " Address ------------------------------------------------------•------------------------------------ ----•- ----. City /- ----- -------------------------------------------- ------ - A Contractor's Name - -did- o X44- �j---------------------------------------------License #CZ26,5_�l Phone ! Installation will serve: ., Residence ❑Apartment House,❑ Commercial :❑Trailer Court i❑ 1 Motel ❑Other ---------------------------------------- -- Number of living units:__./____ Number of bedrooms ____________Garbage Grinder --------- Lot Size t^ Water Supply: Public System and name ---------------------------•------------------------------------------------------------------•-----•---------Private Character of soil to a depth of 3 feet: Sand'D Silt'❑ Clay ❑ Peat❑ Sandy Loam] Clay Loam Hardpan ❑ Adobe'❑ Fill Material --------- -- If yes, type _____.__________________ r (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) i NEW INSTALLATION:, (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) .. �s/ PACKAGE TREATMENT { ] SEPTIC TANK;[ ] Size--0 5__�X1-V- /_9----- -----_ Liquid Depth __!l______ Cbpacity `,� Type PW4� �� _Material______________________ No. Compartments - --- Distance to nearest: Well � ____�,U__-_____________`'Foundatio[� _.___._____.____-___ Prop. Line ---- -------- � F LEACHING LINE No. of Lines ____- -------------- Length of each line----ICJ`V------- ------ Total Length _ __-__________-- - ..D' .Box ---(------- Type Filter-Material _') ` / Depth Fil-ter Material ___ _ ________________________________ Awe � �. Distance to nearest: Well _________/Q�_______ Foundation _ __C>_____________- Property Line, _/rte_________--•--__ SEEPAGE PIT [ ] Depth 1Z------------- Diameter _________________ Rock Filled Yes No .0 Water Table Depth ------------------------------••----------- ---Rock Size ------------------------ ------ Distance to nearest: Well ----------------------------------------Foundation ------------- _____ Prop. Line --------- ------------ C REPAIR/ADDITION(Prev. Sanitation Permit# _______.____________________ Date � } SepticTank (Specify Requirements) ------ -------------------------------------------------------------------------------------------------------------------------------------- I Disposal ----------------------------- -- Disposal Field (Specify Requirements) ----------- - ------------------------------------------- ---- -`------------------------------------------- ----------------------------------------------- ------------------------------------------------ --------------- _ _________________yr ._ __ _ . ___________________________________ _ _ _ ________________________________________-_._______ ___------___.______________________________-___________________________.___________________. (Draw existing and required addition on reverse side) 1 hereby certify that it 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.-Son Joaquin Local Health District. Home owner or Ilcen- 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 $ uble to Workman's Compensation laws of California." Signed ---�` - -- ---------------------------------- ____ Owner BY ------------ -- --------- ---- -------------- --------------------------------------------------------• Title -------------- ---------------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY = ---------------------------------------------------------------- ---- -------------- DATE ------------------- BUILDING- PERMIT ISSJJE�L_------------------- -- - - - --- --------------------- -------DATE -------------------- ADDITIONALCOMMENTS -------------- ------------------------------------------------------------- ------------------------------------------------------ ----------•---------------- I "n ------------------------------------------- __- Final Inspection b _: .� GC - ^� P Y. F C- ------ ------------------------------- -------Date C.... SAN JOAQUIN LOCAL HEALTH DISTRICTy - w E. H. 9 1-'b8 Rev. 5M A