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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _...., C Permit No. 76' (Complete In Triplicate) .............. ..... . ................................ ............. This Permit Expires 1 Year from Date issued 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 Regulotionss JOB ADDRESS/LOCATION ...moi.- til ....... /`irF.: ... ...CENSUS TRACT Owner's Name ��11. Gfi7n, .� 7 .................................Phone ...__..... .................... Address /�� `.-... .. ....... .... ..City . ................. Contractor's Name . r ....................License #OK'ti�,:?�'Phone ............ ..__ Installation will serve: Residence©Apartment Housefl Commercial-oTraller Court 0 Motel ❑Other............................................ Number of living units•_.-,.... Number of bedrooms Garbage Grinder .l,/'.. J lot Size Water Supply: Public System and name -----------•---•....................... ........_.._................... .......................Private ®: Character of soil to a depth of 3 feet: Sand Q Silt Q Clay ❑ Peat Q Sandy Loam 0 Clay Loam Wa,00&' aC] Hardpan❑ Adobe 0 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 feet,) 1 l �`-•f.l .�X.. f....... Liquid. Depth ... .. .............--- PACKAGE TREATMENT SEPTIC TANK Size Capacity Typed`' _- Material �1 /�.. No. Compartments ----�.......... Distance to nearest: Well _. - -- ----------------Foundation ./_4..f__...... Prop. Line ---'`�.A0.... LEACHING LINE No. of Lines --....�'_____________ Length of each linee....5?..$.. ........... Total length ...1.7e. ....... 'D' Box T.t . Type Filter Material /4Depth Filter Material .............•----............. f ."Distance to nearest: Well .,C..le.......... Foundation ............. Property Line ...11....i.d!....... SEEPAGE PIT Depth ... Diameter ,,' ��- Number ---- .''- __.-_. Rock Filled Yes.R1No Q Water Table Depth -------_-----_--- ........Rock Size .I...r^._r .. -------- Distance to nearest: Well ----��.. ..................Foundation Prop. tine 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 Heal&Dlstrict. Home owner or 11Nn- 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 ..................... s ------ Title _. "+c' T� . (1 r than o ner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...... ... . ._ . .. ...................................---•------------ -------. DATE l _ ._.�) ----------- . --------.- BUILDING PERMIT ISSUED -----_--------==- =`-----------------------------------.__........._....---DATE ----- ....................•------ � : ADDITIONAL COMMENTS _____________ .. ---------------------------------------------------------------•-----•---•-••--•-----•-------------•------_....---_,....._._.•-------•-------------....------------------------------ .._._.. .......... ----------------------------------- - . - �------------ ----------- .. ------ ..........:.............•---•-• ....................................Dtea _ ..... ..Final Inspection by: 13 2a 1-6v• 5mSAN JOAQUIN LOCAL HEALTH DISTRICT 874 3M