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0 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) ----------w'------- ---- This Permit Expires 1 Year From Date Issued Date Issued Applidation is hereby made to the San J aquin Local Health District fora 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/LOC --=-------1--- C- 77---------r------ ----------- ------------------------CENSUS TRACT __.-S_-Y-7----------- Owner's Name --------- - --- --------- - ------- ---- -------- Phone yy ------------------ Address.----------/----� ------------ ------ ------------------ City - Contractor's Name ---------- -_-- ------- _ ---------_--.License #';Cy/'7- Phone W- Insta(ation will serve: Residence Apartment House Commercial ❑Trailer Court i❑ r. } Motel ❑Other -------------- -----------------=- ------- j - �p G.. Number of living units:---- Number of b drooms _`_______Garbage Grinder -_-C✓---- Lot Size Water Supply: Public System and name _-- ___. ------ev ---------------------------------------------------Private ' Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Cray ❑--.`Peat F] Sandy Loam ❑ Clay Loam ; rHardpon ❑ Adobe ❑ Fill Material ------------ if yes,type ----------------------------- (Plot plan, showing size of lot, location of system in relation to,,kyells, 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__ l f ( � / ,_ --- ell .- 4' ------ Liquid Depth 0---- -------. Capacity/,2DG_17 Type �- -- - ---- Material__ No. Compartments w�- --- r Foundation 4 proms /' Distance to nearest: Well ___ ________ _ _____ p. Line ______ _.....-.-______ --- LEACHING LINE ' No. of Lines Length of each line-._ �___._____ Total Length __a ....___._.__ 1 t At 'D' Box .-/------ Type Filter Material jr ----Depth Filter Material _/R'---------------------__ ____________ v Distance to nearest: Well --- Foundation ...f�F__r._________ Property Line _ -_ ____-_____ SEEPAGE PIT A Depth Diameter Number ______4%?---------------- Rock Filled Yes L�( No 0 Water Table Depth ------ --- :------------- ------ -Rock Size -----vi_,`-r-._.._---.---- �- #� Distance to nearest: Well .___ COCl_____________________Foundation -_-_�'�__-___ Prop. Line _..__s_______.___.. REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------.Date ---------------------------------- Septic ----_---------------------__ _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. 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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed - ------ -- ------------------------------------------------------ Owner BY ---------------------- ----- o57--116-/ Title .. � ------------------------------- (If o er than owner) JFOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ___ _ _____ _ _____ _ -------------------------------------------------------------- DATE y" -7- '---------------- BUILDING PERMIT ISSUED --------------------- -------------------DATE -----------------------------__ ADDITIONALCOMMENTS ------------------!-------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - --------------- `----------------------------------------------------------------------------------------------------------------=--------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------- = �.. ; -------------------------------------------------------- ------- - ------- ------ ----- - Final Inspection by: Date . ..�_... r SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M