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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT {Complete in Triplicate) Permit No. ..................... .............................................. Dote Issued 2�1.:.3/: S •.........................•.....----••----........_."-.. . This Permit Expires ? Year From Date Issued Application is hereby made to the Son 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: 77� � S JOB ADDRES�/L30CAT ON { 2 J y. ...... _. ...CENSUS TRACT Owner's Name ...... .✓�Q, /_.------- f -- .-....I-------- . ....... .�:J................. .....Phone Address ................ �_. ./ .._.------------------ city Contractor's Name _17.- sj :cv S �-cJ,'� ..................license # Phone Installation will serve: Residencevo�Apartment House C) Commercial❑Trailer Court r] Motel ❑Other............................................ Number of living units:------_--- Number of bedrooms Garbage Grinder I/VNI Lot Size Water Supply: Public System and name ___ ................. Private Character of soil to a depth of a feet: Sand Silt❑ Cloy ❑ Peat❑ Sandy Loam p Clay Loam ❑ Hardpan 0 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 feel) PACKAGE TREATMENT { l SEPTIC TANK{ Size....SVMO.....•-----------_........_. Liquid Depth Capacity ---------------- Type)OA-;�,CJ43 Material_44_9 1k.V.Z7 No. Compartments Distance to nearest. Well O ' -- ----------•.. ............•---...Foundation ..........._..-----... Prop. Line -----�d LEACHING LINE [ J No. of Lines ----�.------."•. Length of each line------ 7o#al Length ..IC's'*-............ 'D' Box ..-S,... Type Filter Material . .tea "-----___._.Depth .Filter Material ""f?................................... C Distance to nearest: Well .....................f. Foundation ---------- --------- Property Line ......................... SEEPAGE "a [ ] Depth ��_.._•- Diameter�feXta.__ Number ..--..___"-�C!:.�uu.. Rock Filled Yes)< No 0 S Water Table Depth .......... ....................Rock Size .. __I��......._...._ 7+ d �{ Distance to nearest: Well __.� ..............�•-.---..Foundation ......-- Prop. Line .��_......._._._ � REPAIR/ADDITION(Prev. Sanitation Permit# ................... _ Dater----- Septic Tank (Specify Requirements) .................=.....--•....................•........... ................... ... . .. - Disposal Field (Specify Requirements) .....-- "_- -------------------------------------------.-_-----_••-.---_"-•••-•--------------.....-•-----------'--•--.........................................------..._......... __ ._.................... --------------------------------------------------- ___-- .................. ..............................___....._.._._.......__.._.._____:.........._..._.____._._................................. (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. Horne owner or licen- sed agents signature certifies the following.- "I ollowing:"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 beco;7e�ubjectokman's Compensation laws of California." Signed --- --------- n BY --- --- - --T-ton-owner) ---------- Title - --------------------------------- {i o#her "' FOR DEPARTMENT USE"ONLY APPLICATION ACCEPTED BY -_ ----------• •------- - . DATE ._....�+ •.'a- 'r1S... ------ BUILDING PERMIT ISSUED _.._- ...........................DATE -- --------- . _ . - _... A DITIONAL COMMENTS --------------------------- -------------------------- ------------._...------------------------------•-.............. ••------------------...-_-.. ------......._-..-•.....................-•....................................... -------------- ---- -------------- - ---------------------------- ------- - ----------------------•----- -.. .........•---------- _ ---. --------------- Final inspection by: "--- --• • ..:...Date _...... . EH �3 2L 1-68 Y• 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M