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FOR CE USE: i ............................. ... ..-_..__. ----- APPLICATION FOR SANITATION PERMIT ----••--- --- pp {Cam lets in Tri licate3 Permit No. ..77-'. ............. . . -. ........ ........."...___-___.._._._. ....._.._...-•----... This PennItExpires 1 Year From Date issued Date Issued . .-/ -. 7) 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; 549 and existing Rules and Regulations: JOB ADDRESS LO TION' Z Z ' ........................ .•..... ...........CENSUS TRACT Owner's Namerte,-z,C_ .,... Address Ane ......... .......................... ..... .,,. City Contractor's Nome •--- :_.......License # .��..,:�� .. Phone Installation will serve: Residence.ElApartinent Houseb Commercial[]Trailer Court Cj 5 Motel 0 Other ............ Number of livin units .......g : Number of bedrooms __.._Garbage Grinder .... ....... Lot Size Water Supply: Public System and name - � ------ ....................... ..-........Private Character of soli to a depth of 3 feet: Sand b Sift a Clay_.❑_, Peat_0_ Sandy Loam ❑ Clay Loam Ej Hardpan 0-I" Adobe 0 Filt;Material ............ If es e (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 avoilable within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK l Size............................................... Capacity :_ Liquid Depth ................ ---•- --------•----- Type _ Material=------------------ No. Compartments Distance to nearest: Wel! Foundation ... ' ... Prop. Line ...:...................r LEACHING LINE [ I No. of Lines Lengthr,of each line.__.__...___.. __ �eqgth'of ...... Total Length g ©' Bax .._._.: T Filter Material-,"i ....................Depth .Filter Material ........ . Distance to'negrest:.Weil .........1,....... FoundationProperty bine .....................--- SEEPAGE PIT [ j : Depth ._. . .:�-.-----:.... Diameter -•-----•--• -,-- Number ..................... Rock Filled Yes [3 No C]� Water Table Depth _.....__._:'......_ ----------- --- -Rock Size ._... Distance to nearest: Weil ......................................foundation .:.................. Prop. Line ................... F ,t REPAIR/ADDITION#Pr®v. Sanitation 4Permlt# ..............-._.._ # _....... bate __.-... ) 4 Septic Tank (Specify Requirements)..------------------------.....................,..._...__. - -- Disposal Field .(Specify q -_--• d__-- ,-- • - ecify uire ( P Re ments) _ {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 Regulaflons of the San Joaquin Local Health:District. Nome 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 ------- ------------------ Title ----- i (i other than owner) � ' - ... -•�-- ----•....................... -• , OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- --------- BUILDING PERMIT ISSUED _'... r.- ;....TM - - -. DATE . /1._.7.--�... . --- . ADDITIONAL COMMENTS ................. .............DATE ------------- •------------••------- ••----.. -.---- ... ------------ .......... -------------------- ----- -------------- ----•- .. Final En - ------- - -------------- ---- -------------------•-------....._-----......--------•------ ._.--_ !.,_- - - - --•...:............. ..• .......................................Date . . ..._ EH 13 2 i-6t3 Rev. 5i JOAWN LOCAL HEALTH DISTRICT 8/7!i 3M