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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7C -/�3 JC) Permit No. .......:...... ....., (Complete in Triplicate) ..................:.........•--- Date IssuedThis Permitlrxpires 1 Year From Datelssued e X20-Z7- fates 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 ad famplf nc v�jth�Cu�y Ordnc� ` 549 arlo Rules and Regulationse JOB ADDRESS/LO TION ... . .....................:...........471- ...CENSUS TRACT ..._.... ................. Owner's Name .- --, U.p,,r.s . .. �_ ...... ,�/�}f' -.•�• 1 i� P .......................•.. Address .. , _ f'i-• .�/'/------------ City _..r j� �.t....... .......... .. ...... Contractor's Name ----- ---- - - ------ --------------•----..License # Phone ` = ../ Installation will serve: Residencepartment House❑ Commercial❑Trailer Court 0 / Motel []Other ----•-----------------•-- -------------- Number of living units------- Number of bedrooms .......Garbage Grinder _ _ .. Lot Size . /...y- - -----••---- Water Supply: Public System and name --------------.......---------------------••--------------.....................-.............................Private Character of soil to a depth of 3 feet: Sand Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan [3 Adobe ill Anterial .,,4&? If yes,type............... ............ [Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse side.) NEW INSTALLATION: . (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANKSize.--. ........... ..... Liquid Depth ---... ao 2 �. �p'`rJ o. Com ...... (11' Capacity ._� ._.....--•__-- Type _lLl�-��Materia .._. . __ Compartments ------....._� a Distance to nearest: Well ----. . Z?....._.. .......Foundation ----��'./....... Prop. Line -,. .......... rn � f LEACHING LINE [A�o. of Lines -.,;L .. ......... Length of each line. . �".I.......... Total Le h �.�..............•- r♦ 'D' BoxKo-nearest- y Type Filter Material/!_-p.�.....Depth Filter Material .. ................................ . Distance Well Foundation ------ Property Line ._. -. ......... SEEPAGE PIT [Depth .. .� �._--- Diameter ...��.. ._�'. Number'..... _.. ....,..... Rock Filled Yes a]---44o-03 Water Table Depth .-J---- Rock Size .. . � .3._..: Distance to nearest: Welly...... 1 °... . :.......:.....foundation ..., Q_.------_.,Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------• ...........r-----•--- Date ............----------------------) �1 SepticTank (Specify Requirements) .. .......... ...............................•....................................................-............................................. Disposal Field (Specify Requirements) ------------- -•-------------------------------- ------------------------------ •-----..--------_--_....:.s_........ . ------------------------------------------•----•-----• -----------••---- ----------------------------- .........-•......................... --------------------. (Draw existing and required addition on reverse side) I hereby certify that 1 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." 14 Signed ----------------- -- -------------- .. ---------------------------------------- --------------- . -------•.-._---------------- •--------------. Owner By --------------•-....---- ----------- ------ Title ----------— ------ ..------ (If t er than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .... DATE W1 3.1.7.6------------- BUILDING PERMIT ISSUED -------------------------------------- -DATE .....-..:.--------------------•--------.--- ADDITIONAL COMMENTS ----------------------------------- .................._...------ -----. ---------------------------------- --------- -----------•-- .......... ---------•------------- ......................... ...................................... ---•-------- ....... --•-•- •• ---------••--- --------- ----------------------------------------- ...... - final Inspection by: .. : . ..... Date ------------- EH 13 24 1-68 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M