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FOR OFFICE USE: T APPLICATION FOR SANITATION PERMIT 77_`�1� ► Permit No: ................................ (Complete in Triplicate) ...................................... p Date Issued .: .z__..7, This Permit Expires 1 Year From bate Issued .. . . ............................................ i m'it to construct and inst ll the work herein Application is hereby mode to the San Joaquin Local Health District for a per. described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. 5-7 !V CENSUS TRACT .............:........... JOB ADDRESS/LOCATION U-0 ..___... ..__.. .•-•••_.:-. --••------- Phone .Owner's Name :..._.. Ail----- ---- -----•-• Address ----.......... . .e..............•.................-...........:........................... City _._ ............. ............. ...................... .......... Y. ..License # -- -.. Phone ...........:......:......:.... Contractor's Name ..--••---- Installation will serve: Residence ❑Apartment House 0 Commercial ❑Trailer Court ❑ Motel ❑Other ..........................-................. Number of living units------------- Number of bedrooms ............Garbage Grinder ............ Lot Size -_---------------- ---••••••.... Private Water'Supply: Public System and name .............. ................................................... ._....._............. ❑ 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,) ...--- -... Liquid Depth _....___........-•---•-•- PACKAGE TREATMENT ( ] SEPTIC TANK 13 Size..................................... - No. Compartments Capacity Materia .............. ....:.... Foundation Prop. Line .' Distance to nearest: Well ............ ------_.. •----•- LEACHING LINE ( ] No. of Lines ... Length of each line__________________...-__-___ Total Length ....__._._..... ............ ' --- --•--•....................... 'D' Box ___.._.. --- Type Filter Material ....................Depth Filter Material 0O Distance to nearest: Well ._...... Foundation .... ..... Property Line -:............ ......... r Depth Diameter ....----••----- Number ............................ Rock Filled Yes ❑ No ❑ F SEEPAGE PIT [ 3 - WaterTable Depth ------- --------------••-----_.._::,--••---__---Roc Size ........................._------ ,4 --•••Foundation ..............:..... Prop. Line •-•--------•-•-•---7-- Distance to nearest: Well ................................... REPAIR/ADDITION Prev. Sanitation Permit# ................................. t Septic Tank (Specify Requirements) ....................... -- - ------- ....... � � .... � :...._ -- ............... Disposal Field (Specify Requirements) ________________________ � ' ...............•-•...---------------- ...... ..... ...... .__... .._._. __....------. •-- -------- _---------------•--- ............ •-••--------...._.._..__...-----.. ........................ f (Draw existing and required addition on reverse side) i 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: y "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 ........................................... Owner ...................................... Title ....................................................... (If other than owner) -' FOA DEPARTMENT USE ONLY j DATE ... _. _�. �.. ...___.... APPLICATION ACCEPTED BY ,/L/ -•......--•..._...-•----........ DATE BUILDING PERMIT ISSUED ....................... ADDITIONAL COMMENTS __.....••------..._ ---.. __----•• ••-•-- •--•...................-•...............---•• ------------------------------ ---------•••-- _.. x .....................................• _ ._._...._... ........................ •••-_..---...__........-••---......__-•. ....-- ---.._.---•---• •• •••- •.... _ ....:-...... -----•...---••...............• ............................ Date ............... i Final Inspection by: --••••-••-••--•----•-•••--.._..... . SAN JOAQUIN LOCAL HEALTH Ql5TRiCf 7/72 3 M _ .. z 9/,L Gll -- - - -