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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .,, (Complete in Triplicate) Permit No. _._72--__7_q_2-- ------- .72--_7O-7!------- ---------- --- ---- This Permit Expires i Year From Date Issued Date 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 < f�J--------- -(,,d(=_ ,C'-ifs' - ---------.CENSUS TRACT Owner's Name ._ 7 ------------------- ------•----------------------------------- ------ ------Phone ---- - ------- ------------- Address7-- - -� Contractor's Name -- ---------r - l------------------=--------License #/77M/----_ Phone _. Installation will serve: Residence [ Apartment House-[] Commercial:[]TraiCourt ❑ � Motel ❑Other ___--- Number of living units;--__.___._-- Number of bedrooms ______.Garbage Grinder IV Z4--- Lot Size 3�-! ,300 x ` -= ------- ------------------------------ Water Supply: Public System and name ----I. --------"------•----- ----------- ----------- - -------------------- -- - -------Private ElCharacter of soil to a depth of 3 feet: Sand' ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam:-O Clay loam ❑ \ Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type �1 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.] NEW INSTALLATION: (No septictank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT [ ] SEPTIC ) Size----------- ------------TANK'[ E _-._____- Liquid Depth ___________________ �. - ---------- - Capacity _'----------------- Type -------------------- Material-------------------- No. Compartments-- {� -------------------•-- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ----------------_-•--- LEACHING LINE [ ] No. of Lines ---- -------------------- Length of each 'line--------------------_------ Total Length ------------- --- - ----------- 'D' Box ----........ Type Filter Material --------------'___--Depth Filter Material ___ _ __ 1 -------------•-----•---- 3 Distance to nearest.-Well ________________________ Foundation Property Line ------------------------ SEEPAGE PIT Diameter --__-_--_ Rock Filled Yes No i0 [ 1 � Depth - --- ------------- � Number Water Table ..Depth -------- -----Rock Size .! Distance toinearest: Well ----------------------------------------Foundation % --------------------- Prop. Line --------- •-•---------. REPAIR/ADDITION(Prev. Sanitation Permit# -.-----_.--`----------------------- Date --------_--------------------_" ] -. 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 Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance ofkthe 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 -- - ----- -- - r) ------------------------------------ Title ---�/�2��.7_.--------- ---- johe� th owner] '- ---- -------- -------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--C-- - BUILDING PERMIT ISSUED --- ----- -------------- ----- -. DATE,-2- .-Z'-'--------------- ----------------------------------------- k � - DATE y ADDITIONAL COMMENTS -------------------------- -- -------- -------- - - =----- ---- -- ---------�1_ 71_11;; ------------------------- Finaf Inspection by: �- - ---- -- -= ---------------------------------------� - --------- ---------------:------------- - - ---- - - - ------------Date -- ----- ----- I ..SAN,JOAQUIN LOCAL HEALTH DISTRICT d. 9 1-'S8 Rev. 5M '