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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .................................................... Permit No. ..77`.... �0 4 (Complete in Triplicate) .......... .. . . . . . . . .4 .................................. .... ... This Permit Expires rl Year From Date Issued Date Issued Application is hereby made to the Son Joaquin Local Health District for a permit to construct and in-stay, the work herein described. This application is made 'in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB-ADD ESS/LO("TIONx/ .4 .Rr ._ w ,rg ,ya. G1 ...CENSUS TRACT .......................... Owner's Name .0 ... - .{ . . �. .. .Phone .................................... ......_� ......... ............ .... Address r�... :City . tiContractor's Name ......�p�.. c... ............ ......License # � �'...... Phone .............. ............... Installation will serve: Residence l]Apartment House❑ Commercial❑Trailer Court 0 Motel ❑Other ..<_... '-' -e. .. -a�-.._ Number of living units:....... Number of bedrooms 3.......Garbage Grinder --_-______.. Lot Size ...��----�-�_ I ......... Water Supply: Public System and name -------- -------------------------------------------- --------------• .....................................Private Character of soil to a depth of 3 feet: Sand ❑ i t❑ Clay - Peat[-] Sandy Loam E] 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 see ge pit permitted if public sewer is available within 200_ feet,) PACKAGE TREATMENT �F � [ ] SEPTIC TANK Siae.. . --•- --- -- -------------------- Liquid Depth Capacity -.j%Z .�-b-•-- Type .... -�"� Nlateriai.F- -fir_ No. Com artments >. 10 Distance to nearest: Well .........,G.0.. ...............Foundation -.--.----.. Prop. Line ...-^5...._.....-\ i LEACHING LINE [ ] No. of Lines ......3---------- Length of each line---...*,P./.......... Total Length ........... 'D' Box ....1_:'.... Type Filter Material .:_"5. -....Depth Filter Material ........... A---•............J.......... "4 Distance to nearest: Well ......:5,P_ ......... Foundation ...1P_ ___________ Property Line ....6 ... ... Q SEEPAGE PIT [ Depth .. ......._._:. Diameter ... :y.. Number ------- .................. Rock Filled Yes �No ❑ Ile % Water Table Depth �.RA.........A................Rock Size ..1:�..�.. I -------------- ......... Distance to nearest: Well ---------- Foundation ...-._4D._..:..... Prop. Line ...1�........:....... REPAIR/ADDITION(Prev. Sanitation Permit# . Date t Septic Tank (Specify Requirements)].................. .......... f...._. 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 of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Work n's Compensation laws of California." Signed ...................... :.: _.: :......._.. Owner KA By ................................... �� .. ._ .y- xitle ... (If other than owner} FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. ---------------•------- -------- --•----------•-• -------------------- DATE ---- /O 7.; ..-------- BUILDING PERMIT ISSUED ......... ...... ..•• -_:... .. :.., ...:..__... = PATE, ADDITIONAL COMMENTS ..IOC.17t ,.... _.-..- T .:. �p - - `•- -" i................... . .. �+.. ...._.... Gl.� :.....:........ -------------..-----..._..............--.-...----•----------------------._........... ... ..................... ............................................... Final Inspection by: ..............1 ........................................ -- --••• Date ....'.. ------- I SAN JOAQUIN LOCAL HEALTH DISTRICT .E. H.13 24 1-'68 Rev. 5M 7172 3 ,K