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EOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 76- 77 IComplete in Triplicate) Permit No- ------------•-..... . " ' 3-,��:7 •---•-----•................................•_............ This par+r�it Expires 1 Year From Dah Issued Doti Issued •---.... .... Application is hereby made to the Son Joaquin Local Health District for a permit to construct and Install the work herein described. This application is made in compliance with County dinance No. 49 and existing Rules and Regulations: JOB ADDRESS/LOCATION . .6-1 J _. �: . ... .�..Y... ,1� !- CENSUS TRACT Owner's Name _. ' - •-•..... ....................:................Phone ...._............................... ---- , r E Address .... . ...._. City .........................•_._.......... ..._... ....._......_........_. --•-- ---• - Contractor's Name ---•--__- -- ---------- ---- --�_......... ....-•-----•_...License c - � -. Phone .{ I� l��r Installation will serve: Residence partment House Commercial oTrailer Court 0 Motel ❑Other Number of living units:....I 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 p Gay o P t❑ Sandy Loam 0 Clay Loam o 4 Hardpan o _Adobe Materlal ._..........if yes,type............... ............ (Plot plan, showing size of lot, location of system In rotation to:wells, buildings, etc, must be placed on reverse side.) _ k NEW INSTALLATION: (No septic.tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT"I.,.[I. SEPTIC TANK Size................... ............ Liquid Depth .......................... "[opacity l----•„--•-••• --- 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 ............................................ Distance to nearest: Well ........ ............... Foundation .............. Property Line .._. .......... SEEPAGE PIT [ ] Depth -----I.............. Diameter ____..__ --.---- Number __.......................... Rock Filled Yes ❑ No i. Water Table Depth ... _----••------......•••__.._...Rock Size --••............................ l ...Foundation . Prop. Line ..Distance to nearest:-Well-^._-•..........:..:....._..-------•- ------•-------..... .:..:...........----- REPAIR/ADDITION(Prev. Sanitation Permit# ..............-------.................... Date ---•--..__.:...........:-__....... ) Septic Tank (Specify Requirements) ....................... . .. f — .`._.� . :..�.-. ...- �...._.......:... _..... ..... ... Disposal Field (Specify Requirements) _.._..... .. .-- --•---....-•- -------------- ---------- •-----•--•- - -----------------•------,............----_,......-......................------..._..:-----.... 4 (Draw existing or d 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, acid 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, 1 shall not employ any person In such manner as to become subject to Workman's Compensation laws of California,” Signed ----- Owrier B5 ................................... `J'Itle, C1 2 } ............................ BY, {If otpUtf.�han owner} . i FOR DEPARTMENT OSE'ONLY APPLICATION ACCEPTED BY _ -----•---- ------------------------------------------- ----------- DATE 7_.6_..-------------- ABUILDINGPERMIT' ISSUED ------------• -- -•--= -- -------••---•---•----------------„__..---------•-------.,-••---....---DATE ,_----- ............. -------- DDITIONAL COMMENTS .. _--------'-•--- ------------------------------------ •--•----:_.-... f -- tt 11 r ----- ------------------------------------ ----- ---------------- --------DoteFinal Inspection by.. 0.... ...... �__, I ' EH 13 24 1-68 Rev. 5M � SAKI JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M