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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ...................................................: ................ ....... ...................... lComplete in Triplicate] Permit No. ..7...: ./. ... this Permit Expires ] Year From bah Date Issued ._ TT Z?:�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. 5.49 and existing Rules and Regulations: VJOB 2ADDRESS/LOCATi _. 4 /� f� �� .................................CENSUS TRACT .......................... Owner's Name ..- u> .....phone -------------------------- Address -•----•................. 0A.C!*......_.... Ci Phone Installation a 7(, Contractor's Name ---•-•---- ------------------ � ---!,�±�:�' ---..._...._._.....--------•..........License # installation will serve: Residence R�par_tment Houseo Commercial OTraller Court 0 - Motel ❑Other--------•....... .......................... Number of living units:...... ---- Number of bedrooms ....Garbage Grinder -- -C-;- Lot Size .... . .. ....... ... ......-........... Water Supply: Public System and name - ..... ......... ................................... Private1 Character of sail to a depth of 3 feet: Sand Silt Q Gay Peat Sandy Loom 0 Clay loam ❑ Hardpan 0 Adobe Material y4,.P._ 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} j Size....................................- Liquid Depth Capacity -----------•--_- Type .................... Material...................... No. Compartments ...................... Distance.to nearest: Well ....................................Foundation ...................... Prop. Line ...................... LEACHING LINE; [ ) No-of Lines ........................ Length of each line.+..........................- Total Length ............................ 'D' Box _....._ .... Type Filter Material ____________________Depth Filter Material .._.._....._..__......__....._.............. . __ Foundation . Property Line Distance to nearest: Well __..-•--••-- ........... ----................... ........................ 0 SEEPAGE PITDepth .-•-------- --------- Diameter ................ Number _....---.................._. Rock Filled Yes ❑ No (] ( l Water Table Depth --.............................................. Rock Size •---------..._. ................ Distance to nearest: Well -------.................................Foundation ---................_ Prop. Line ................... REPAIR/ADDITION(Prev. Sanitation Permit# -----------------------------------•- ------ Date .-....................... ...._....} Septic Tank (Specify Requirements) ---_-------------..__. ..... .......................... • •-----..........._. ...�.............. l 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 Son Joaquin Local Hoal&,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 Workman's Compensation laws of California." Signed --------• ------------ - ------------ y�,� ._ •--------------------.......... Owner �w By .._.._.- ------ -- ---------d/ '``'------------------•-•------------------- Title /� `l --• ................... (!f r than owner) FOR DEPARTMENT USA.CNLY APPLICATION ACCEPTED BY -----_--------------------- DAT! ..,r .-L.7.'76_..._..._.._.. BUILDING PERMIT ISSUED ....... . ---- -------------DATE ........---------------................ ._.. ADDITIONAL COMMENTS .............................-_---•--••--•-----•• - - • ------------------- ---------------------------------._.._........- ---•---•-- --•---- ................................ ------------------•---- ---------••--------•-•------•--------••------------------------------------------------------------------------ ..................... InaInspection by: -•----------------------------- --------------....----- .__.._...._._.. Date _.....-d.7..- .�_......... .._. 13 -� SAN JOAQUIN LOCAL 141EAtTH DISTRICT 8/74 3M `Q