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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ._.7 7 .30 (Complete in Triplicate) _ _ �_...q. Date Issued ed .................... _....... s-�e .......------................................... This Permit Expires 1 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 with County Ordinance No. 549 and existing Rules and Regulations: p JOB ADDRESS/LOCN � ....... .. _ _ ..,.. ..... ..... .. � ....Cl NSUS TRACY .......................... Owner's Name .i�._.. .. . ^.�..._.. .. Phone . ................................. ........ Address . _ .....f�.�6: --. 1 / City .... ' Contractor's Name........... .: ..(.... .. ... .... .._. . .� :, )lanae .� _ Phone ............................... F installation will serve-. Residence 0ARartment House fl Commercial ❑Trallor Court 0 Motel ❑Other ............. Number of living units:.......... Number of bedrooms ....;5...Garbage Grinder ............ Lot Size ...... ......••-- Water Supply: Public System and(name .... ..........................................-.........................................:.....................Private ❑ �. Character of soil to a depth of 3 feet: Sand 0 jSilt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ , i Hordpan-0 Adobe 0 FIII 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,( PACKAGE TREATMENT [ ] SEPTIC TANK ] Size................................................... Liquid Depth .............I............ Capacity ---------=---------- Type .................... Material........................ .No. Compartments .....................,6' Distance:to.nearest: Well -•.................... ...........Foundation ...................... Prop. Line ...................... I LEACHING LINE [ ] No. of Lines ........................ Length of each line------ _-----•............ Total Length ................... ... Z ` D' Box T Filter Material .......Depth .Filter Material ' -- Y6� Distance to nearest, Well ........................ Foundation ...................:.... Property Line .................•.. SEEPAGE PIT [ 1 Depth ................. Diameter Number ............................ Rock Filled Yes (3No 0 Water Table Depth .......--------------------I......... ..........Rock Size .---•-••----.. ................ Distance to nearest: Well ........................................foundation -;.................. Prop. Line ...................... �t REPAIR/ADDITION.IPrev. Sanitation Permit# ...........................................•. Date ..................................A - I SepticTank (Specify Requirements) ...:........................................................................................... ...... ........................... Disposal Field (Specify Requirements) ... ---•� _:_..��. ........................ .................................... R -------- -------------------- -----f --. ---••--------- ---- ---- - - ....... -----------•-- ....... .............- .................. ............. (Draw existing and required addition on reverse side) 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 Joaquln Local Health.District. Hone* owner or licen- sed agents signature certifies the following: "1 certify that in the performance of the work.for'which this permit is issued, I shall not employ any person in such manner F as to become subject to Workmeia's Compensation Iawe of California." ` Signed --`----------------•-----••-----,--•-----t ,: --------- • /� ------- Owner r �. ........... ............. B - 4� i-x - ----- -----. title (If other than owner! FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .... AV_X_- - --- - ---------- DATE: .:_� :.. ............: BUILDING"'PERMIT'ISSU€D _. �----------• ~-� --- ---•-- -- •.................... .....•---•--- ------ ---- -----------DATE --- .............................. ADDITIONAL COMMENTS ----- '---------- --------------- --------••-----•-------------------------.-..--............:------------- ......................:........................... C ---- ----------- --------- --------I----••------- - --------------------------------------..... ----------------•---................................................... ----------- -----------------------------•-------• •- ---.._...:_.. ----------. ---------............ •------•---------....... ............ ---. --- • ---------------- - � �• ----•- -••.. ... final Inspection b -•....... ......Date ..- _ ._ .. ..............---- P y: ...-----•----- r r • EH 13 2h 1-68 Rev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 87)1 3M v�