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FC--OFFICE USE: ' APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. 77...:. -5..� . .................................. .. 1Date Issued ........................................................ This PermExpires pires l Year From Date Issued ; Application is hereby made to the San Joaquin Local Health District for PP Y q 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. / _�/ .. ..................................... ......................CENSUS TRA ..�OwPho ner's Nam ne ... � 3 .. 3®.7� — •--. Address ......... ......................................... Cit .................... ............ Contractor's Name �� ',r�'-/! ........License # ,��✓5..''^ - Phone X441 t' Installation will serve: ^ Res Residence (AApartment House❑ Commercial ❑Trailer Court jMotel ❑Other ...... • ............................ Number of living units:.._/_...'Number of-bedrooms ` .....Garbage Grinder Lot Size ................... Water Supply: Public System and name':..........I..............x.... .....Private, Character of soil to a depth of 3 feet: Sand Yj (Silt❑t Clay ❑ Peat❑ Sandy Loom Clay Loam ❑ Hardpan❑ AdobeA Fill Material ............ If yes,type ........................... t (Plot plan, showing size of/lot, location of system.in relation to wells, buildings, etc. must be'oloce`d on reverse side.) O f NEW INSTALLATION: (No septic topk or seepage pit permitted If public sewer is available within,200 feet,) PACKAGE TREATMENT ( ] SEPTIC TANK J Size.,.....,,,..,n„T.r.......................... Liquid Depth ........................... Capacity .................... Type .... ............... Material...................... No. Compartments ...................... `t ----Distance-to--nearest:Weil=.....................•..............Foundation ......_........- ! . .....'Prop..Line:-•--.....-•---....... n LEACHING LINE [ J No. of Lines ........................ Length of each line............................. Total length � .._......... Type Filter Material ....._..Depth'Filter Material 'D' Box .......�.... Distance to nearest: Well ........................ Foundation Property Line ........................ . , .% SEEPAGE PIT [ I Depth .................... Diameter ..............:C-Number,%.......:............._..::: Rock Filled Yes ❑ No ❑ � j Water.Table.Depth { Distance to nearest: Well ........................................Foundation K................. Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit#f.. ..... . ........7.................. Dote .........C.1.........._..) Septic Tank (Specify Requirements) .. [f. ."..,1..: Q. ��%.. /f/� ,. :_ ,1�!1�j°'yr� / j!7 ;_..•-„r Disposal Field (Specify Requirements) l • ...........................•---.......-- -------.... .-- •--------•--•.. ....... ..... .--•-- ... .......--- ..... .............................................................. (Draw existing and required addition ori-reverse side.). 1F. 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 awnar or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, ) shall not employ any person In such manner i as to become subject to Workman's Compensation laws of California." Signed .. •-•-- •.. ..... ............... ... •• ......................................... Owner By ...........:............ .. .. ....... title _ .. i (If er than owner f FOR DEPARTMENT USE ONLY {{I f APPLICATION ACCEPTED BY ..--- .................................... DATE ...... . ... . ...... ............... i BUILDING PERMIT ISSUED ................. ........._............................:..............DATE .............. ............................ ; ADDITIONALCOMMENTS ............................•--..._......-------•-•--------------------------....._.__.............---••-------. .._.......................................... ; ..._ --•--•-•••-----••-•----••--------•-•••-•------•--•-•------•--••...............•-•---•--••-...... f ..................................................•--•------.......:.....-------•--...............-----.............----------....------------......._............_•--••••. ....................I...........--••--........ .. :_..... .. _.................................._................... Final Inspection by Date `� �� ..... ..... . .._ ...............................•......-----•. ••-•-.................. ......... l //// SAN JOAQUIN LOCAL HEALTH DISTRICT E.H.13 241-'68 Rev. 5M 7/72 3 M