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F M upplu u5et APPLICATION FOR SANITATION PERMIT .......... .. ....................................... Permit No. . 77--i G 3 ,k ................... (Complete In Triplicate) . A•�...�..�.... . ....... This Pen�nit 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 C unty Ordinance No. 549 and existing Rules and Regulationst ev JOB ADDRESS/ .......... -.-...'.. .......... .....CENSUS.TRACP Owner's No a .�.. ................ .. ................................... ..... ......Phone ...................... Address ••--- ..................... City . -- -•-•---......... ..... .............. Contractor's Name . =f/ - License # `.ZPhone Installation will serve: r/ a dente ►partment House] Commercial❑Traller Court 0 Motel[]Other--•......................................... Number of living units:..-•=-_-•--- Number of bedrooms � Garbage Grinder Lot Size ' '- ' Water Supply: Public System,and name --- -- g --- ----- -•--•-------•--- ...-----'.._. _...... .............................__-----•----...........-..--..--...........................................Private 0 Character of soil to a depth of 3 feet: Sand Ej Silt❑ Clay ❑ Peat❑ Sandy Loam ❑. Clay Loam ❑ f Hardpan❑ Adobe❑ 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•ililiij ] NEW INSTALLATlONa (No septic tank or seepage pit permitted'if public severer is available within 200 feet,) T' PACKAGE TREATMENT [ SEPTIC TAN { )Size : :# _y_.. : .:.... '` Liquid Depth' :..... Capacity ._ ��.�Ataterlal ': --------- No. Compartments _. ......J Distance to nearest: Well .............Fooundation ...................... Prop. Line _ LEACHING LINES ( ] No. of Linea .••---•-.-•------__-- Length of ch II --__--. .Tota! Length ......................... . . t .., _._ .. �,� , n I ti 'D' Box ..�-.. 4 Type Filter Mdterlal .-•_-- - 'Depth*filter Material .. .. ... .... ...... .� -- _ :. w- Distance to nearest.'Well oundation Property Line' ............:......... I _ ................. _.................----- SEEPw, A IT`}[• Depth ............. ,^.� Diameter ................ Number .... Rock Filled Yes ..No (] j Water Table Depth _. ' . ........................ - . ._... Rock.Size -- .. Distance to earesf: Well ..................... .... ...Foundation ....... - ....... Prop. Eine ........ ........... y a REPAIR/ADDITION{Prov. Sanitation Permit# ............................................ Date ................._.......... Septic Tank (Specify Requirements) .....................................j! -• -- .................. ......._..... ...... Disposal Fiela (Specify Requirements) .' _ I - .................................................. .....•---------.•--------- ..................... .._............------- ................... .................---.._.............;._......._....---•_....._--. ......................:.............................................................................................__..._.._..._..............._............ ........ .. ................. �.. (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 wlth San J004aln County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne ow'ner,or licen• I sed agents signature certifies the following: _ e •-•� "I certify Thal in the performance of the work for which this permit is Issued, I shall not employ any person in suchmannet as to beco sub�e to Wark an's Comp ns n laws of California." z t , Signed ... - ..._. . ....--------- --•-•-- .. ........ Owner By ................ . ..................•-•.......................................................---.. Title .....................................::......................... If other than owner) j FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 8Y .- :.. DATE...:. ""9' .............: _ 1 ....... ............... BUILDING PERMIT ISSUED .................... QATE ........ . ....................-......... I .......................... ADDITIONALCOMMENTS ...............................................................-.._--.----•---•.............-......................................:............................ .......................................••---..........._....-- -- ................ ...................................................................................I...............-_.. __ r EH 13 21a 1-Gt1...-.. 3fay. .......... ..... .. ... ......-......-....`..... ...................... t . ..... Finalpion by: .. . '. .,. - -�--• ---•---•---•---------------..: V .Date .-3-=��':`'��............ Insect ..... � SAN JOAQUIN LOCAL; HEALTH DISTRICT 8/7h 3M 4..