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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ...._.... _ _ (Complete in Triplicate) Permit No. ....:77.33 - `�.77 .......... ....................................... ...... 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 mode in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION Q.SS_ X, =t,W __... �!d` _.._.-__ ..__...... .. --..CENSUS TRACT .......................... Owner's Name _..�� R -?! !..... 2�tt ---- ---- -------------- ---------- - - Phone ... Address ._. City . ._:. .../ ... ............................ Contractor's Name . Arr- ..............^�i.... ... ...License # . -8. &_...... Phone .............................. Installation will serve: Residence 03"Apartment House❑ 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 C] Peat F1 Sandy Loam [Cloy Loam 0 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 side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK[ ) Size----.__...............__._._ - Liquid Depth .......................... Capacity ._ 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 [ J Depth Diameter _.............. Number 11 .......... Rock Filled Yes ❑ No C] Water Table Depth - ---- .. . ----- ...Rock Size ... -....._--_-----_---- Distance to nearest: Well __ ..........................Foundation _ ._....._ ....... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ......_ ._ _._ -..___..... Dote ..............___.............) Septic Tank (Specify Requirements) ....... -.............. Disposal Field (Specify Requirements) 4,0_e (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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed Owner By . .- .. . .... ll.� ,G"` (l� Title �a ��•a _ . . (If other than owner) F_O EPARTMENT USE ONLY APPLICATION ACCEPTED BY - _ _ DATE ./ ! 3 _ ....... BUILDING PERMIT ISSUED . _ _:.-. _ _ _ ...._-DATE ADDITIONAL COMMENTS ............... ................___ _... ... .. - ------------------ Final Inspection by. . . ................ ........................ ..... ...._... -...........Date . ..---- -----..-.......-- SAN JOAQUIN LOCAL HEALTH DISTRICT ° E. H.13 241•'68 Rev. 5M _ 7/72 3 ,K