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FOR OFFICE USEt a k G1®f,Q i VISE'_•{- I Z C� ' APPLICATION FOR SANITATION PERMIT ....................................................... IComplete In Triplicate) Permit No. ..77: " Date Issued -4......................................................... This Permit Expires 1 Year from Daae 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 County Ordinance No. 544 and existing Rules and Regulation r .. ,r.R.ci.....cs TRACT .......................... JOB ADDRESSAOCATION .. `��_ fa._.. ...... Owner's Name e—- _ . . .... . . .........................I.....................................Phone --.------------------•-.--_-------- Address .. �•----------------------------------------------•-----------.._..-----•--.City ---................................................................... .Contractor's Name ----------40,Ce . .......................................................License* .0 f -- Phone Installation will serve: Residence T-X'p�artment House❑ Commercial❑Trailer Court Motel❑Other............................................ Number of living units------------- Number of bedrooms ---I.......Garbage Grinder ....... LotSlzo Water Supply: Public System and name •................................__.--................._........................................_..........Private❑- Character of soil to a depth of 3 fest: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy LoamClay 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 silo.) 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 ...................... I LEACHING LINE [ J No. of Lines ------------------------ length of each line............................. Total Length ....._..._................. 'i?' Box ....1 . ... Type Filter Material ....................Depth Filter Material ............................................ ) Distance to nearest: Well ........................ Foundation _-...................... Property Line ........................ 60 SEEPAGE PIT [ } Depth ..._ L8 t-. Diameter Number ........../............... Rock Filled Yes &O"No ❑ Water Table Depth ••-•----•---.......--••.........................Rock Size ....14,..................... Distance to nearest: Well ........................................Foundation .................... Prop. Line ....................% REPAIR/AUDITION(Prev. Sanitation PeTtnit# ............................................ 5 . �... Date .--•--.._._...--•--•---._.........) Septic Tank i Requirements) Disposal Field (Specify Requirements) -----------------------•----------•---------.-------•------•-----------•------------•--•------ ----------------------............... � _Z*- ................................... ------------------------- .................................................................................................................................... •-•--------- ------------ ----------------------- ------- --------- .... ..............................-............................................................................................ (Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joagvin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Heakk District. Herne owner or NOW sed agents signature certifies the fallowing: "I certify that in the performance of the work for which this permit is Issued, 1 shelf not employ any person in such manner as to becom i t t kman's C%npensatlon laws of California." Signed __ .. ------ . --`-- ........................... --•--•---- ._ .._.. ................. Owner By -- -- --- ------ - -- --------------------------------- Title .f � r---...-.....-.-----------...._..........-.------ ( r than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _. DATE --._.. ......... BUILDING PERMIT ISSUED ... ---------------- ----.---------------••-.----- - .. ._ -- ---.....DATE ..... --.. .....---.. ............_. ADDITIONAL COMMENTS ..................._........ ........................................ •............. ......... ...................... ............... . ----------..-- ------•-- - ----- ------ .............. ................................................. ......-- .........------.------------........._........... ...... ---- --- - -- ---------- ,.. ---------------- ---..... ..- --------- ......... ---•---.. ............_-................. ...................... Fina Inspection by: -• - ---------------------------------- ----.--.-Date .._.. ... rr-. T. ........--- EP 13 21t 1-613 Rev, SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3M