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r%.m %jrrn-c u �— APPLICATION FOR SANITATION PERMIT ...................................................... (Complete lei Triplicate) Permit ................................... ..... . . ...... This Permit Expires 1 Year From Dat*issued Date Issued 6..: 77-. 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. 544 and existing Rules and Regulatlons, JOB ADDRESS/LOCATION .!�`�� .✓.. -cam.. ............................................................CENSUS TRACT Owners Nome . .�.� .................................................. .Phone . ., 2:�......... Address .2� �- . ....I--r......... . ... . ...._.. //e city ............... ............. .................................... Contractor's Name ... .... r � •-•----•.................•-----........-•------License '. ..�. ..... Phone ��_ ..... Installation will serve, Residence Mllcp-artment House Commercial❑Trailer Court ❑ Motel❑Other...........-•........................••--•-- Number of living units:............ Number of bedrooms -_5.....Garbage Grinder ............ Lot Size ............................................ Water Supply: Public System and name ..................................._---------------------_-------...........................................Prlvcft�----- Character of soil to a depth of 3 feet: Sand❑ Sllt❑ Clay ❑ Peat❑ Sandy Loam ❑ day Loam o Hardpan E3 Adobe❑ Fill Material ....-....... If yes.type............... ........ ... (Plot plan, showing fixe 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................................................ Liquid Depth ....................:..... Capacity JZZ A&d pe -..��'.....��y�- Material...................... No. Comportments""". Distance to nearest: Well Me/ ..Foundation .............. Prop. Line . .. S LEACHING LINE [ j No. of Lines .............i__.`(,ength of each line.. - ................. Total Length ..1,............... 'D' Box J........ Type Filter Material .----Depth Filter Material ........................_..... r Distance to nearest: Well. ...----------I........... Foundation ........................ Property Line ....................... SEEPAGE PIT E ! Depth ............... Diameter ................ Number ............................ Rock Filled Ye: ❑ No ❑ Water Table Depth ---••----•........................•----.........Rock Size ................................ Distance to nearest: Well ....Foundation ..... Prop. Lina REPAIR/ADDITION{Prov. Sanitation Permit# -............................................ Date .:...:..::..,..:.`_.:_...__.)_- Septic Tank (Specify Requirements) •-••...........................•-... 7......................................... ...................................................... •a DisposalField (Specify Requirements) ...............::..............•-•--....:_..--. ..................................................................................... ..............•...................---..............................................................---._.....----r-•--•----1 -•---......................_............---•-•.................._...._... --•------------------------•-------------------.......... ----•---•---........... .......... ....-----.._.....`......... ` `.:. ._ ............................... (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that .the work will he done'iri accordance with San .Joaquin County Ordinances, State Laws, and Rules and Regulations of the..San Joaquin Local Wealth District. Home owner or Iicen- zed 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 as to become subject to Workman's Compensation laws of California." . .rte •• Signed -Z ...�...... .. ..............:...:Owner By ................................................... ----......--•---. Title .............-----.................. ..-----...... .......... (if other than owner) FOR DFOARTMfT USE ONLY APPLICATION ACCEPTED ........DATE 8Y .. `` .._.._ ..... . ....:.......:.........-...-.....- BUILDINGPERMIT ISSUED .......----------- ............................................................DATE _....................----.................. rADDITIONAL COMMENTS ..............................................................,--.---•--..-.................-..............I....I...... -..................................... -•-- ......................... .......... ......I............... ........................ ..................... ....... Final Inspection by Dote ... -...- ............ ................ ._.. 13 24 1'6 v• SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M