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e FOR OF#�ICE USE: CDD(0 C-a.Otto APPLICATION FOR SANITATION PERMIT ........._.. ..... ......................... 7 Permit Na. .........:�� ........... (Complete in Triplicate) .........._....................................... .. Date Issued 6 -/ 77. ........................ This Permit Expires i Year From Date Issued .......... ...... 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 w'ifh County Ordinance No. 549 and existing Rules and Regulations.- JOB egulations:JOB ADDRESS/LOCATION .:�.' 6...5,1' ta�'•?o�!¢ -Z. ,' .A""4V V`,"V A-'Vr-2 C%vG...CENSUS TRACT .... ......... . . ...... ..... Owner's Name ......R.eq. `!9•'�-•-•••-••................................. Phone Address . 1 d-�.p-pp t' ,.!� svti.......l c'�..........................................'City ....-n�)e ........_............................. ......... Contractor's Name ... .. A' �*�� 50W License # ��6.- ' Phone .--------•------ ... .. .........................•------....... .... ......... Installation will serve: Residence 13 Apartment House 0 Commercial ❑Trailer Court 0 Motel❑Other ............................................ Number of living units:..,./..... Number of bedrooms .........Garbage Grinder ........y.. Lot Size ...sa_.'�..��'p..................... Water Supply: Public System and name ...............................................................................................................Private ❑ Character of soil to a depth of 3 feet: Sand D Silt❑ Clay ❑ Peat❑ Sandy Loam 0 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 seepage pit permitted if public sewer is available within 200 feet,) C} PACKAGE TREATMENT O SEPTIC TANK-1J Size................................................ Liquid Depth 1aoC�t / eC ,yeo�vt . .. Capacity ...................• Type ......._............ Material......-----..._....... No. Compartments ...................... �. Distance to nearest: Well ................Foundation 7C `.......... Prop. Line ...�E........... LEACHING LINE ( ] No. of Lines Length of each line.X................ . Total Length 'D' Box ...A...... Type Filter Material ?� ...Depth Filter Material .....Z y.'.`_..:. Distance to nearest: Well ........................ Foundation .........-..._. pert) �� ........ Pro line .... .: SEEPAGE PIT [ ) Depth .................... Diameter ................ Number ......................r.,.. Rock Filled, 'Yes ❑ Nc-(j.. 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 application and that the work will be don* in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Mom* owner or licen• sed agents signature certifies the followings "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" Signed ....e!�7----14 .Tl)c IK . ............................... Owner By .. .. ... ... ................................................. Title ............................... .................................... (If other t a e FOP DEPARTMENT ISE ONLY APPLICATION ACCEPTED BY ........... DATE BUILDINGPERMIT ISSUED ........................ ................................................................................DATE ........................................... ADDITIONALCOMMENTS .... --•-•--•--•- •.............................................:....._..................... ............:.•--•....----•.---• ...................... ........ ....._.... ............................................... Final Inspection b . .. .. .Date . ...... ... p y ........ .. .� .:. .. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.13 241.'68 Rev. 5M 7/72 3 M