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F FOR OFFICE USE: G APPLICATION FOR SANITATION PERMIT ------------------ - ----- i `'- (Complete in Triplicate) Permit No: ._ _77D tt' 1. --_-___ This PDate issued ermit Expires 1 Year From Date Issued --_-^-29` - Application is herby made to the Son Joaquin Local Health District for a permit to construct and install the work herein f described. Tga,is'appl•ication-is-made in compliance h County. Ordinance No. 549 and existing Rules and Regulations: ' ------------------------- ----CENSUS TRACT RACT ---------- JOB ADDRESS/LOCATfON 1 Owner's Name ----- --------------- Phone------------- --- ------ --- -- 73 7 Address - --- ----- -- ---- ---- ----------------`----- - City }, ((`` ------------------ - � -------------- Phone ------------------------------ Contractor's Name -____-__� _- _ _-_ ____ ----d. _._ License # ____.-_-__ fnstall tion will serve: Res idenceApartment House❑ Commercial❑Trailer Court i❑ Motel Otherl --------------------------------------- �� Number of livingunits: Number of bedrooms __,I_.____Garba a Grinder _.--__--.--- Lot Size _.._ 9 Water Supply: Public System and name ------------ -------------- "'----------------------------------------------------------- --------------Private . 1 ,y Character of soaoa depth of 3 feet:.Sand Silt Clay'-- eat❑ Sandy Loam ❑ Clay Loam Hardepa❑_ Adobe ❑ Fill Material ------------ If yes, type ---------------------------- M1 {Plot plan, showing e of lot,�ocation 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 isewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size-____-_____-_____I-____ -______--__ _ Liquid Depth __________________________ Q Capacity -*-, Type Materia l +A ` No. Compartments Distance to nearest: Well __Foundation ---- - ------------ Prop, Line - t LEACHING LINE [ ] No. of Lines ..-------. - Length-of each line_____________ __. _____._'Total Length ---------------- 'D' _--'________'D' Box _.__ Type Filter Material --------------------Depth—Filter—Material ----------------------------------------_--- Distance to nearest: Well ________________________ Foundation --------------- Property Line ----- _-_--._-__._____ SE_PAGE PIT [ ] Depth --- -------------- Diameter �-- - Number ___- -- ---- - Rock Filled Yes E] No [3 , u Water Table Depth -----------------------------------------` , Rock Size ----- ---- -- ------ - Distance to nearest: Well -------------- ------------------I-----Foundation .--------- --------- Prop. Line ...................... R_PAIR/ADDITION(Prev. Sanitation Permit# ------ ------------------------------------ Date ----------------------�----------- } , Septic Tank {Specify Requirements}_--- ---- Disposal field (Specify Requirements) ---------- __/0 ------- -------------------- --------------- --- ------- ------------------- -I-------------------------------- ----------- --- ----- --------------------'-------------------- --- -------------------------------------------------------- ' ' ----------------------------------------- ------ -------------- ----------------------------------------------------------- �r 11 (Draw,existing and,re.quired 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 an Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: A "I certify that in the performance of the woFk 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.'�.�..,.� -1-- Signed -----'-'----- ------------ ---------------------------- Owner BY ------ Tite ---- ----- - ---------- ----------- i owner)I OR DEPAitTMENT USE ONLY APPLICATION ACCEPTED BY _ _ -- ----------------- DATE ----_ ._- -6- ----------------- "+ BUILDING PERMIT ISSUED ------- -- DATE AD pl�q LO T5 a ----------.---- - ---- ----- -°�'3- - I--- ------ ---6k -- --- ----------------------------------------------------------------- - - --- -------------------- Final Inspection by: ------ Date .. SAN JOAQUIN LOCAL HEALTH DISTRICT k:> E. H. 9 1-'b8 Rev. 5M