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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT •• Permit No :77.-/70 (Complete In Triplicate) � �•� �- . h .. T Date issued This Permit Expires I Year From Dole Issued .. .: �...�� k .................... ................ 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 .�.��._........�. .. .. ............... ...,..........................,.CENSUS TRACT ..i.....................'- Owner's Name -. - ✓e, _ .... •.. . Phone :. .Address . .. ..... Up,�- .�.......,.- ..... ..... .V .... ... City . .....�L s .` .�?..-....: r Contractor's Name ..-. --....fc.... ,.License .� z-. Phone ............................. Installation will serve: Residence[ Apartment House E] Commercial❑Traller Court fl v I Motel ❑Other ............. .............I.................. Number of living units .--- Number of bedrooms _2- '_Garbage Grinder ............ Lot Size ......................... ................Q Water Supply. Public System and name F ....Private Character of soil to a depth of 3 feet: Sand❑ ilt❑ 'Clay ❑ Peat❑ Sandy Loam ❑ r Clay Loam ❑ - Hardpan Adobe ❑ Fill Material ............ If yes,type................ ............. E (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) y NEIN INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) � PACKAGE TREATMENT [ ] SEPTIC TANK I ].. _: - ...." Size...................................I............ Liquid Depth .......................... Capacity ---------------- Type ...... ...... Material................ .. No. Compartments Distance.to nearest: Well ....................................Foundation ...................... Prop. Line ...................... LEACHING LINE ( ] No. of Lines .................... Length of each line.------.------- ---- ...... Total length ....-_ ..................... � 'D' Box ..-..._..... Type Filter Material ....................Depth .Filter Material ............................................ ' Distance to nearest: Well ........................ Foundation ...................:.... Property Line ........................ tNumber ...._.---... ... Rock Filled Yes No SEEPAGE PIT ( } Depth --•------- --------- Diameter ............... --•-•- ❑ 0 Water Table Depth .................................................Rock Size ............------ •--••--•-• • r Distance to nearest: Well _....Foundation ..................... Prop. Line ] REPAIR/ADDITION(Prev. Sanitation Permit# --------.- .-------•................... Date _:._..--.:-------.____.------_A Septic Tank (Specify Requirements) • --- -- f'------------- -------------------- . Disposal Field (Specify Requirements) .orf .- -• . ..............F..... � ------------------------------------------------------------------------------------------------------------..........--------------------------------------------------------.................... ....... (prow existing and.required addition on reverse side) I hereby certify that t 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'whichthis pernnit is issued, I shall not employ any person In such manner as to become subject to Workman's Compensation laws of California." Signed ..... ............ ............. Owner I By ---------------------------------___ 'c-- -. Title E (if other than owner} �r t FOR DEPARTMENT LISE.ONLY APPLICATION ACCEPTED BY ------- = _ / ...... _- ..._...rpATE . _� ..` '. ,?...:........: .._ . BUILDING PERMIT-ISSUED .-.l..- -------- • DATE . ........._-....-....:.. --- ---• ------..--•-------- ADDITIONAL COMMENTS ---- --------------_-.-_ - � ----.....-..--- ..--..............--------....... ----------------=-------------------------- ------ ---...........--------• • ------------ --------- ................................................... --------------------------------... Final Inspection by: ............................ . :.. . Date _. .: .. _.- j7' . - ..-...... . �' Eft 13 24 1-613 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3M