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FOR OFFICE 115E: APPLICATION FOR SANITATION PERMIT ....................I........ .......1.11 Permit No. ..77^. bS? u (Complete in Triplicate) ....... ............... ......•.• This Permit Expires 1 Year From Date Issued Date Issued � '::7 Application is hereby mode 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: f JOB ADDRESS/LOCATION ....�. _ ._.._..... [..._.._ . . .......CENSUS TRACT ......................:... Owner's Nome ._._.. .._fr'- - .... z ..........................._......._... ................Phone .._.........._.... ................. City.._... t Contractor's Name # �a :. '��lPhone Installation will serve: . ResidenceAApartment House-EJ Commercial ❑Trailer Court ❑ Motel ❑Other ....-- •.............................. t Number of living units:...../-..:. Number of bedrooms ----._Garb Grinder : Lot Size f,-,�,, �_. Private Water Supply: Public System and name ----. .. - - -_ --�1 G ----�---•---.......................................•---------• • ❑ ; Character of soil to a depth of 3 feet: Sand n Silt❑ Clay ❑ Peat❑ Sandy loam ❑ 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,) PACKAGE TREATMENT' [ SEPTIC TANK.1 l Y ize _----------- Liquid Depth ................ ...-._... Capacity .. ---- Type Material-------------- -------- No. Compartments Distance to nearest: Well .- ........ -------------Foundation ... ................... Prop. Line ....__....... ..._. _. S LEACHING LINE No. of Lines .-.� ---. ..-.. length of ah line....._. ..c �.._-....._. Total Length ... O D' Bax .. . Type Filter Material v ---/C----Depth Filter Materiai _..� ................... ....:... ._ Distance to nearest: WeIILl��_f Foundation ._`fir_...- Property Line - _._.. .:._.: .... SEEPAGE: PIT " Depth `.f_.._. Diameter �r._ Number ._...... --- --------- Rock Filled Yes No Water Table Depth ...... -------------------- ---Rock Size --------- Distance to nearest.- -0-77 4 _ 4�.........:......... _ -.-.--- ... . ...__ Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# ------------- -----.---------- Date ._...--------_--.--------.....--) Septic Tank (Specify Requirements) _ t �c --------- --- fDisposal Field (Specify Requirements) ____ fi '..�� ___ ____________ ..----- ------------- - ........ _ ..... --- ._.... ................... , •.... ............. ......... (Dra'w 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 District, Home owner or [icon- 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 jas to become subject to Workman's Compensation laws of California." Signed .. Owner , BYL_�.... . ....... ._.........- ----------Title ------ ---• (If other than owner) FO DEPARTMENT 015E ONLY i APPLICATION ACCEPTED BY ..._.. N.._. .. .. .. ' BUILDING PERMIT ISSUED ..... -- ----- ------• _- - DATE _ _....-... ....._._..... ADDITIONAL COMMENTS .......:.......................•-- . --.......-------- --•---• .... ....... ------------------- : - :....-. 17 ; .y . ---... --------- - ._....-- -------- --- - -------- .._.._ ---.: ...... Final Inspection by: ----..._--- ----- -------- ------------- --------_ __-•----------- ._.._......Date ........ ... ._2�-_------ SAN JOAQUIN LOCAL HEALTIH DISTRICT - o _ 7/72 3 , . E i, 7.3 2 � ��e e_._ eu � _ ,