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FOR.OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ._77 _��._. This Permit Expires I Year from Date Issued Date Issued ..F�?'1-_7J 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 1_34; -7 ......-u.� ... . .. ..... ......................CENSUS TRACT ......... ................ Owner's Name ..� _-. -_.... .. ................................. ....: .............Phone Addresses 7 :... ... .... .. . .. City ... � .. .. .............. Contractor's Name ' r� .... ..... . ...•--....... :...Lloense . f c�✓ Phone Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 0 Motel ❑Other............................................ Number of living units:-..-/.... Number of bedrooms _.:�.Garbage Grinder Lot Size Water Supply: Public System and name ........................................................................................ ............. ....Private Character of soil to a depth of 3 feet: Sand E] Silt 0 Clay ❑ Peat❑ Sandy loom Clay loam ❑ . Hardpan ❑ Adobe ❑ Fill Moterfol ............ If yes,type ............... ............ (plot pion, 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,) l� PACKAGE TREATMENT [ ] SEPTIC TANKS ] Size........................................ ... Liquid Depth 6 Capacity -------------------- Type •--•_...--••-------- Material.----------........... No. Compartments ......................moi Distance to nearest: Well ....................................Foundation ....................... Prop. Line ...................... LEACHING LINE [ ] No. of Lines ............ ........_ Length of each line............................. Total Length Z 'D' Box ............ Type Filter Material ....................Depth .Filter Material .............I...............I- .......I Distance to nearest: Well ------------------------ Foundation .......__............... Property Line ........................ SEEPAGE PIT [ ] Depth --- -------------- Diameter ............_-.. Number --------------_............ Rock Filled Yes ❑ No ❑'f 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) .. - ................................... ---- - ----------------- ----••--....__.......,.....- ------------------- ---------------------.... ---. ........................................................ {Draw existing and required addition on reverse side) I hereby certify that I have prepared this applicalion 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:Dlstrict, 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 shalt not employ any person In such manner as to become subject to Workman's Compensation laws of California." Signed ----------------------------- Owner By _.......----•---------••---------- ._.... - Sitle _.. .� � .._..._.. (if other than owner) FOR IDEPARTMENT USE ONLY r� APPLICATION ACCEPTED BY .------- ----•--- --------- -- DATE ,_ /._- ---...-- BUILDING PERMIT ISSUED ---------- ................... .. . .. . . -•-- -----------------------•------- _. ADDITIONAL COMMENTS .. ...... DATE . ..... .................................. ------------------- e -- ------------ --------- -------------•-- /. Final Inspection by: --------------- C- -- Date ..... _. ------------ ------------------ ----------------•---- 13 2!t -.EiI3 Irv. SM A JOAQUIN. LOCAL HEALTH DISTRICT 8/74 3M