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FOR OFFICE USE: PLICATION FOR SANITATION PERI"` ........................... � �G;� (Complete in Triplicate) Permit No�...--: ............................. ............................... 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 T hi.4 application is made in am Ii nce CouOr in c an exi ing Rules and Regulations: JOB ADDRESS/LOCAT ....:.....CENSUS TRACT ...................... . ......... - --------------- ✓ Owner's Name ----- --- ------ -• Phone . .` ........ Address -....---- 3 ------ 1 " '.-------------_------- ------------ City � ........._ ...................... Contractor's Name .......... --- ----- ------ -- --------------------License # s .- .` .. Phone ..........-................... Installation will serve: Residence ❑Apartment House Commercial [:)Trailer Court ❑ �, Motel E]Other V4� �,-4 e. _ - - Number of living units:............ Number of bedrooms --------....Garbage Grinder ------------ Lot Size ........ ...a.e_L> ......... Water Supply: Public System and name ...--.-•-•-------------------------------------•-------------....,.--------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam X 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 V,jNo septic;ian'k or.steepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTICq Tr-T NKjj,,j, Size.... 1y......................... Liquid Depth ....... ......... Capacity r--. .-.-..# Type ...fNXJ__.__ Material;;:{ No. -Compartments ----�._.__..._ _. i V Distance to Jnearest: Well..-.. :'... .............___........Foundation ......... Prop. Line .......... LEACHING LINE No. of lines .....-- .;-___.:Length of each line .__.-�CT - -.-----_ Total length _.� _..._.......... D' Bax .--....... . - . Type4ilter,:Material _ ----------Depth Filter Material .................... Distance to nearest: Well ....,.............::: : Foundation ........... Property Line ...1r,.f............ SEEPAGE PIT [ ) Depth .- ,lDiametgE_ ................ Number - .----.---.------:_--_ -- Rock Filled Yes ❑ Na ❑ a,.. Water Table Depth ----••------•---...-..-•..............•---------Rock Size -------------------------------- Distance to nearest: Well ............................... ':......Foundation .................... Prop. line .... ........... REPAIR/ADDITION(Prev. Sanitation Permit# ..............................................Date .................................. ) Septic Tank (Specify Requirements) ------------------------------------------------------------------------------•-•----••------- ..............:.------- — :..._ Disposal Field (Specify Requirements) ------------------ ----------------- ---- t ._ _ ......... ......................... -----------•. ...........................•------- ...--.. --......--•---.........-- -- ----------------.-.-.-............:_,....-..------.-.-...--.._...-....--....-----------.------._.,- (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: u "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." g .- �---------. _.7 Signed ..- •--• •._jote ...... . ..._.- .. Owner By • -- `Wf ` Title � �............. .............--------.._.--........ pthan owner) a FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED; ,8Y : ............. ---------------•--•--•-...........------------.-----. '....--_:.... DATE ,.-.�d�-1��•4---------------- .. BUILDING PERMIT ISSUtD'' �.-------------------------- ----•------------------------- •-•--------------...,..--..:..DATE ............................... --------_ ADDITIONALCOMMENTS ...................................... ................... ---------------------------------------------------------------...........-•------------(fig ------ ------------------ ----- .----- - -- Final inspection by: _ __ --- Date b ?� ..---------- . . SA A UIN L CAL HEALTH DISTRICT N JO Q O r; E. H. 13 24 1.'f,R Rav FM 7/77 1 M