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FOR OFFICE USE: APPLICATION FOR SANITATION PI'law;IT (Complete in Triplicate) Permit No. -- ------- ---------------- - ------------------------ °.............-----------------.----------------------- ._ This Permit Expires 1 Year From Date Issued 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: 474 JOB ADDRESS/LOCATION .______ _��-+ 9__S__oe _ _7 Ti--- ►r1 'GcE-___._CENSUS TRACT _____._-__._-______-____ Owner's fume - -o -C2 _ �!!j Phone Address ----------- City Contractor's Name -----------------6Z -- ----------------------------------------------License # ----------------------- Phone Installation will serve: Residence 014. partment House 0 Commercial ❑Trailer Court ;❑ 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'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe 0 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,) �. PACKAGE TREATMENT [ I SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth -___-____.___________-___- V� d Capdcity -------------------- Type -------------------- Material---------------------- No. Compartments ...................... W Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line •_--______-._._.______ p LEACHING LINE [ ] No. of Lines ------------------------ Length of each line-------------------------— Total Length ------ --------------------- 'D' Box ------------ Type Filter Material ____________________Depth Filter Material __._________________________---_•_-__.--__-_ Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ____-_--_________-._-___ SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No Water Table Depth ------------- -------- ---------------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation __.__.--_________.__ Prop. Line _____-_--_______--__-- REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) Septic Tank (Specify Requirements) --------------- .-evr------------------------------- - -----•- Disposal Field (Specify Requirements) --------- -------- --- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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 Workman's Compensation laws of California." Signed ---------------------------------------------------- ---------------------------------------.- Owner BY ----------- ----------------------------------------------------------------------- Title ------------ --------------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ ' f ------------------------------------ DATE --/-77Z/�-Z ------- ------ BUILDINGPERMIT ISSUED ----------------------•-------------------- ------ ------------------------------------------------DATE ---•----•------- -------------------------- ADDITIONALCOMMENTS ----------------•------------------•-----••------------••------------------------------------------------------------------------- -----------•--------------- -----------------------------------------------------------------•-------.-----••--------------------------------- -••------------•--------•----------------------------•--------------------------------- ------------------------------------------------------------------•-------•----•---------------------------•----------•-------------------------- •---------------------------------------------•--------- --------------•-------------- - Final Inspection b r s'—'-------- --- --------------------•--_-- --•---•---- --------------Date �=_;?/�n7v/---------------------- SAN y: ---------- .�C SAN JOAQUIN LOCAL HEALTH DISTRICT r N 0 1_'ISR Po FAA