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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Gf� Permit No. .•%..1....6,30 ................... ........................ (Complete in Triplicate? —.%, F ........................................ �.3 7, Date Issued .77........J- This Permit Expires 3 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and texisting Rules and Regulations: JOB ADDRESS/LOCATION,/�`' _ ....../V j"f1 6 .....CENSUS TRACT .......................... �- ..Phone Owner's Name ..`�!-/ �. ?C jGrt�r... .... .........•..............•. .....-----...._.... ..............__ Address . �f.- ' °t �f . r�� `�.--•--..... ............. City ........•.......................I....... . Contractor's Name e'.r-Q•"� - _.. _.License # Phone a�f��-�-�/� ' r�?�.._..�r�.•••.•.••• Installation will serve: Residence ZApartment House❑ Commercial [–]Trailer Court 0 Motel ❑Other ............................................ Number of living units:_..1--_._. Number of bedrooms __S...... Grinder -_ Lot Size , �!� ------••-••-•-• Water Supply: Public System and name ----•-••................ ---------..................-_----------_ -•---------- .........Private JN Character of soil to a depth of 3 feet: Sand i] Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam W Hardpan ❑ Adobe C] 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 Size.*_X.!9.•X.4-....... ................ Liquid Depth -��................... Capacity I Type �'� .. Material, r '�1 �- ...... No. Compartments .� t................. �1 Distance to nearest- Well ._r,�`l-____ Foundation ../ ............. Prop. Line ...x-Z.._........ r LEACHING LINE Vd No. of Lines _-- ----_--------- Length of each line..._�j'P................. Total Length .......... 6 'D' Box 44_.'l.-._ Type Filter Material 1�aP4_Depth Filter Material y.................................. Distance to nearest.. Well Z'470 Foundation _._ ..P.............. Property Line IM•••••..I........ 'L �` ......,._ _.::... Rock Filled Yes No ❑ SEEPAGE PIT � Depth _ p�.�_-•---•--- Diameter �.�......__ Number ... __._.. _ • Water Table Depth ... ---..Rock Siiee. .;p.�---------------- Distance to nearest: Well (/.4P' ....Foundation -• ? ---'= Prop. line _�lE ..._._...._ .... �................. Daae •I G; REPAIR/ADDITION(Prev.'.Sanitation Permit# -------.................•................. --.•........------. . Septic TankS eci Requirements) -•---••--•.............. .•---................---...._.....•. •-••-..........-I.... w::......... { p fy Re q •------ --------- Disposal Field (Specify Requirements' ---.....................................=.........._........................---"--- .• 1.....-----•.....1------- oQ -----_-------------------- ................-...............,.._...............•-.......... (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 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California," Signed ---- -------------- --- -- Owner Title ..... (If er than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -&?!'.............................------------......-----------------•------------• DATE ...7 BUILDING PERMIT ISSUED DATE _..:--------:..........:-...•.............. :: _......_._.. :...... ADDITIONAL COMMENTS ll�c F.....................+ 4 ---...-- -•---- . - =--••-•-- ............................_.........---..........--------•••--•-.......... �. .. ...... •_t .................... ----------•--- ..I.........I.............. ..._---... Final inspection by. ---------• ----------•-----•---•------------------------------------- .......................... Date ..... ::.:19._7 SAN JOAQUIN LOCAL HEALTH DISTRICT 7172 3 M F_ K_1.3 241•'68 Rev. SM - _