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• � 1 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ....................................................... Permit No. ..._._//.// � /b (Complete in Triplicate) 77y•'"'�'? � P P ....................................................... This Permit Expires I Year From Dote Issued Date issued ..._......_...�..� Application is herebymade to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made`Iri compliance with Co tyQO,rrdinancee No. 549 and existing Rules and Regulations:' JOB ADDRESS/LOCATION .:.:-. - I �r3. ,.----. .._.._. lw!:,.--. - ` .......CENSUS TRACT ...:..........:.........:. Owner's Namei Phone �jG -.rZ. ...... Address ............................... �'�.� ... ........-• •--- .s............. City --•-- ....................................... �. Contractor's Name .................p...--...... .... ...... _... ........... # . -5 'SLI . Phone �1..._ Installation will serve: Residence'[ Apdr�Hause>�Commercial ❑Trailer Court ❑ JMotel [Pth --------------+--� ....................... �- a Number of living.units:__L------- Number of bedrooms ..x. _.: .Garbage Grinder'_. Lot Size ---------- _ Water Supply: Public System and name ----------------- ----- -'` ..---- : ................ .- ------...-•---•--Private ❑ Character of soil to a depth-,of 3-feet:-..<Sand-'❑—Silt-❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan❑ Ad 9be 1�, 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 TANKI J_� Size................................................ Liquid Depth .......................... Capacity ...._:;............. Type=1 ......��... aterial---_-.------_--_-^ No. Compartments .... 0 T Distance to nearest: Weil: J_ Foundation ...................... Prop. ro Line °G LEACHING LINE [ J . No. of Lines ? _-....... . Length of each Eine.__...... Total length ...-- •-•................ •- ................. " r- 'D' Box ..... Type Filter �terial •...................Depth Filter Material I.....................................•...... � j' l Distance to nearest: Well -...?..._ Foundation ... Pr`perty Line i SEEPAGE PIT [ ) Depth ❑ 0 � r -------------------- i?iameter .•---.........._. Number :,---•-•--._._.............. Rock Filled Yes No t Water—To ble Depth...................!................. ........Rock Size .................. ' Distance to nearest: Well .. ........... ...—•r'r Foundation .......... ).. Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# ......... ._.......4� . Date � Septic Tank (Specify Requirements) .... -... 7----------------- JSpecify Field tlSpecify Requirements) �� _.. l J- --------------------------------------- Disposal Q ` '� - `�`��'�'�-^'s: ---------------•--••---•------------- -- ------------------------------- ------------------------------------------------ ----- (Draw existing and required addit on on reverse side) I hereby certify tout I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws;-+and-•Mules-and•Regulations-oi the-Son-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 p�rmit is issued, I shall not employ Ly person in such manner as to become subject to Workman's Compensation laws of California." Signed [ Owner 0 s � ...............By - Title ._ yy ............................. (If o##, er n owner) FOR QUAKIMENT USE ONLY � APPLICATION ACCEPTED BY -- ------ 1 __ _ DATE=_._ _. 7____•............. BUILDING PERMIT ISSUED .........................•----•- . .................................... -•--•• ....................DATE ..._.....-•--•-•............. ............. ADDITIONALCOMMENTS R :_...........-•-•..........................................•-...........--• .................................................... .................................................................. •-------•-•-----------•------•.........-------•----. • •. ' 77- . ... . .. . ... :.. ..................... ......... .. .... ,- .. Final Inspection by: ...- .... —a . . -----..Date ...................... - ---SAN-JOAQUIN ALO L' HEALTH DISTRICT F w_ 13 24 t.-AA Qo., 9AA 71723-M �