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FOR OFFICE USE: App�ICATION' R SANITATION PERMIT p in Tr (Complete Triplicate) Permit No. Za-77 p e/ k --------- "---" --:'_ --"--- This Permit Expires 1 Year From Date Issued Date Issued 7-_-7- 4 Application is hereby made to the San Jo quin Local Health District for a permit to construct and install the work herein described. This application is made in pliance with County Ordinance No'o', 549 and existing Rules and Regulations: JOB ADDRESS/LOCATI N .-----9(a.____ ___,_-_ - '{�9/ - ---- - ---- ----- - --- - EN C SUS TRACT -------------------------- Owner's Name --- --- ---- --------------- Phone i = Phone7 --- �Address .__. City - ._. ---------- ----- {�� Contractor's Name -- __-- _t-- -- _4_-- __ ,` ---.�(T?'! ,.License #�-C�9: 1t'�__-- Phone _ �-to-9��7* Installation will serve: Residence VApdrtment House-E] Commercial :❑Trailer Court 0- % 13' 740- Motel cyMotel ❑Other -------------------------------------------- Number of living units:---- -_--- Number of bedrooms __ prbcge Grinder _Y- Lot Size _t__________��:_-________�-___----' r' Water Supply: Public System and name __________________ _ __�_-__________Privates❑ -r - $ . Character of soil to a depth of 3 feet: Sand'[] Silt❑ Clay El Peat❑ Sandy'Loam .0; ClaY Loam ❑ Hardpan Adobe% Fill Material ------------ If yes, i (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse/side.) x NEW INSTALLATION:'- -------�W -._.- _ {No septic tank or seepage pit permitted if public sewer is available within 200-feet,) PACKAGE TREATMENT [ SEPTIC•TANK 1 __ _ Size__ ___ _2x_� ---y__________________ Liquid Depth ___ _________ Capacity �f _6 �Type _R --- Material No. Compartments -----�Z .....__... Distance to nearest: Well A_______________________ _ Foundationt � f0 --=--- '--------- Prop. Line ....................... LEACHING LINE No. of Lines __- +_ _______ Length of each line-___-_ ��.___-_ TSotal}itength`.�_�_�Q______________ 'D' Box ___-✓-- Type Filter Material _�$��.-_-.Depth Filter-Material N__�_�`_---�__ ______________________ Distance to nearest:- Wel'l °,_x___ ___________ Foundation _Q'____________. Propeety,l'me lam______ ________ SEEPAGE PIT Depth; ---------- Diameter Diameter ,______ Number ___- ock Filled Yes No �❑ , _... Water, Table Depth-` ----_-----------------------------------------Rock Size-jJ/Z ----- I t Distance to nearest: Well ------->--------------------------------Foundation -10---------- Prop. Line la...!e_.6___. 1 � > REPAIR/ADDITION(Prev. Sanitation Permit# ______________ ------------------ ---------- Date�-____-.__---_______._____________J SepticTank (Specify Requirements) -------------- ---- ------------------------------------------------------------------------------------- •--------------------------- Disposal Field (Sp e fy Req uirements) ------------------------------------------------------------------- ----------------------------------------------------------------- i u i ------------------------------------------------------- { -~ - -------i------------------------------------------------------------------------------------- ----------------------------- ------------------------ ---------- -' y -- ---------------- ---- -------------------------------------------------------------------------------------------------------------------------------------------- ----_(Draw existing and required addition on reverse side) 1 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 perfotmanc of the work For which this permit is issued, I shall not employ any person in such manner , as to become subject to Workinan'siCompensation laws of California." ) Signed ------------- ------- __ Owner ------------------------------------------ BY -------- .. ------------- ---- ---------------- Title ----- / - ------------------------------------------------------ (If o than owner} —FOR-DEPARTMENT—USE-.ONLY APPLICATION ACCEPTED BY s == - - - ----- DATE ��- BUILDING PERMIT ISSUED ---�""=�-------------------------------- ---------- -- - ------'------------------------------------DATE ------------- ----------------------------- ADDITIONAL COMMENTS _____12 _____________ -------------------------------------------------------- --- - ----------------------- ----------------------.------ ------- ------------------------------------------------------------------------------------------------------------------------------- IFinal Inspection by: ------------- ------------------- --- ------Date --- - - --- ---- - SAN -- ---Y- SAN JOAQUIN LOCA. —HEATTH DISTRICT E. H. 9 1-768 Rev:-5'M-- I