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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT r -------------------------•-------------------- Permit No. -V177:3/_/--- (Complete in Triplicate) --------------- ----------------------------- This Permit Expires 1 Year From Date Issued Date Issued ------------------------------------------ -------------- 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 ----- _76--b-,----�-/--- :-----�-�---�"-'----� � ----- -- TRACT __-'Y_7---------•--- Owner's Name -- R. r�,-e!C�` :.. ------------Phone r ,2 7 Address ----- 1' f '`' / City :_ r.E. -----•--- ---- ----------- Contractor's Name -----; ' ' --------------------------------------------------------------License # ------------------------ Phone ------------------------------ Installation will serve: Residence ®Apartment House❑ Commercial ❑Trailer Court Motel ❑Other --------------------------- ---------------- Number of living units:------ Number of bedrooms",2---------Garbage Grinder ------------ tot Size ------------------------------ ------------- Water Supply: Public System and name -----------------------------------------------------------------------------------------------------------_Private ❑ : ..1 Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay .❑ Peat❑ Sandy Loam in 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 side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) _Ij PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depth -----------------•--,----- II;N Capacity ________ Type ___________________ Material_____________________ No. Compartments Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ----------------•-••-- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------,------------------ Total Length :----------.---------------- I 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------•----------------------- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. -------.---------------- -- Number ---------------------- Rock Filled Yes ' No . SEEPAGE PIT [ ] Depth __._.__-_________-_ Diameter ____ ,_______ ---- ❑ (:3 Water Table Depth ------------------------------------------------Rock Size -------------------------------- ` Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------------------.-- µ REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date -------•--------------------------) Septic Tank (Specify Requirements) --------------------------------------------------------------- ---------- -•--- ---------- -- - -------------------- _.----------- Disposal -------;Disposal Field (Specify Requirements) ----- ---- ---- v'-"e --- - ------- ---------------------------- ----- � p7' • --------------- -------__-- ---------------------=--------------------------------- ---------------- ------------- . ----------•-- ------------------------------- ----- --------------------- ------------------µ-------------------------------------------------------------------------------------------- (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 4.I as to bec me%subject to Workman's Compensation laws of California." 4 �r - l. - Owner Signed C r ��: �_ BY --------------- ----------------------------------- ----------------------------------------. Title ------ ----------------------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- ---------------------------------------------------------------------- DATE ------------------•--- BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------------------------------------------------•-•---------------- ------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------ ------------------� i`---- -- f------=---- - i ------------------------------------- --------- ------- i Final Inspection bY- ----- -------------------------------------------------------------------------------------- ! -------.Date ----- � SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M. � F