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FOR OFFICE USE: Y APPLICATION FOR SANITATION PERMIT c ` (Complete in Triplicate) Permit No, 77`-------- ------- ------------------------------------- -------------- This Permit Expires 1 Year From Date Issued Date Issued ___. .ay--- 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: JOB ADDRESS/LOCATION ------------------------ 1✓ '- ►o:1�J R D ) O i-exr _---------•------s- ----�Y CENSUS TRACT -------------- -------•--- �! APhrz :5P )ZAj&- : ----M_�E-L--------� --------------- !�1-1r.---------------------------------- -------d Owner's Name __ one Address --- 3 9 --- ---- ------------ 2 ----------- City --.M_ 1T�C Contractor's Name ......---Cr4_(z C-�e------------------------------- -------.License # _ ��- 9/ - Phone x.73' $ Installation will serve: Residence P0 Apartment House❑ Commercial :❑Trailer Court ',❑ ! Motel ❑ Other -------------------------------------------- a Number of living units:------------ Number of bedrooms ---3-----Garbage Grinder ------------ Lot Size --- ------------- Water Supply: Public System and name ---------------------------------------------------------------------------------------------- •---------Private Character of soil to a depth of 3 feet: Sand'X Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam :❑ Hardpan ❑ Adobe Q Fill Material ------------ If 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 N SEPTIC TANK[ ] p Size------ -- --0- ---------Gori-___--__ Liquid Depth -___--__----------------- Capacity -1-�0 n------- Type Peps --- Material--- No. Compartments ........ ---_Z------------- Distance to nearest: Well ______,5__0'-----------------Foundation -.3P-/----------- Prop. Line ---t�_r_.--- LEACHING LINE [ ] No. of Lines ------------- -------- Length of ach line------------------------ - Total Len t ,........................... 'D' Box ------ ---- Type Filter al ------------------ De i ter Mated ------------------------------- Distance to near t: ation --- -------- --------- Property Line ----------1_:._-........ SEEPAGE PIT [ ] Depth ---------- ________ iameter -- ----- Rock Filled Yes ❑ No 0 i ---------------- Nun r ------ -------- -- Waterle Depth -- -- ------------------------- •------•-- occ - ----------- -------------------- Distance to nearest: W 1 ----------------------------------------Foundation ------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ------- _n1_S_,T « =z 0 0 G 1 PR � 5 r P7-r Disposal Field (Specify Requirements) --_/3N 1<____--A'0-0____----Hoo k v k*(S?-j" [ __ _ _yc t!roll! ,P. ---------- ------------------------ (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 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 beco ubjec Work 's Compensation to of California." Signed -- -- ---- ---' -- -- Owner i By ------------ ------- Title -------------------------- - ---------------- ------------------ (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -_ -- . -.- '23-��y -------------- DATE - �-�..-- --------J-�----------------- BUILDINGPERMIT ISSUED ------ -------------------------------------------------------------------------------- --------------DATE ------------------------------------------. ADDITIONALCOMMENTS -------------------------------------------------------------------------------- ---------------------------- -------------------- --------•------------------ ---- Final Inspection by: --- -- ---------------------- --- ----------------------------------- ---------------Date -- �- ---.��- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M