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F FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .......-•--•... ..................•.:_ 77`2 / ................ ...:.................. (Complete in.Triplicate} Permit o. ..................... This Permit Expires 1 Your From Date IssuedDate Issued .' --_.. 7 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 ...... 77��.:__.�;-- -----1fac,3,7 ----- a/i ---------------• CENSUS TRACT ----••-------...-•----.--- �p ------•- Owner's Name I: fP�#'5 .��4...__CI� .._L:�..��=11�.�� t �?i,-... Phone . -13�7->__.. Address - /. SII. �.r_... --------•---- city •..79' Ci -------•------------•-•••---------------- Contractor's Name .... --------------e -�------------------------------------------ ---------------License* ....... --------- ...... Phone --••-•-- •--•-••----•--------- Installation will serve: Residence Apartment House Commercial❑Trailer Court 0 Motel ❑Other............................................ Number of living units:......t.... Number of bedrooms_-----Garbage Grinder ............ Lot Size Water Supply: Public System and name --------------------------------------------------------.�._.. - -----------•---...........------------Private Character of soil to a depth of 3 feet: Sand❑ Silt 0 Clay 0 Peat❑ Sandy Loam 0 Clay Loam ❑ Hardpan❑ 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 aide.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK I • - , .,. Size................................................ Liquid Depth ........................... . Capacity ---- ----- Tyle ------------------ Material---------------------- No. Compartments --- .............. Distance to nearest: Well ..-•..................--------------Foundation ...................... Prop. Line --.................... LEACHING LINE [ j No. of Lines -------I--.......... Length of each line......... .............. ... Total Length .....______,_ ........ � ` 'D' Box ............ Type Filter Material --------------------Depth .Filter Material ....... .................................... Q Distance to nearest: Well ..---------------------- Foundation --................_ ---- Property Line ........................ e SEEPAGE PIT [ } Depth .................... Diameter -----------..... Number ..----..................... Rock Filled Yes ❑ No C3 Water Table Depth --------................. -------------------Rock Size ........:...................... . Distance to nearest: Well -----....................................Foundotion ....____......_....r Prop. Line ...................... I./ REPAIR/ADDITION(Prev. Sanitation Permit# .............------- ------ Date .................................A � SepticTank (Specify Requirements) ...............-.................................................................. ._....._.._-------•---,. ----- ................. Disposal Field (Specify Require ments) llra ---- - =-L ._.,.. �..:1..ft�.--4) " •--� ....... --- -.TT4 .C-14---•- lw....tLl� , —&....4.a ............................................ ---••-•-------------------------------------------------------- ---- ----•------- ------ (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 becom ubject to Workman's Commpenscidon law of Ca ' mia." Signed.- C=d er By -------------•------------------------•- -----------------------------------........................... Jitle ------------------ (if other than owner) _ FOR DEPAR'ICME T USE ONLY APPLICATION ACCEPTED BY. - - -----:--- _ rt� - ........ DATE._._..._-' ....... ....... BUILDING PERMIT ISSUED -•-- -------- --- -----------------.-DATE ........ --------------------- .-----••--- ADDITIONAL COMMENTS ----- --------- .................... ---------- ------------.._.- -------- ...------ a - - ------- final inspection by: .._.-..- . ------- C '" ..-------•----- ------------------ ---------Date ... w .7...-- ' EH 13 2h 1--68 V. M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M i