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// 77g�- 2 FOR OFFICE USE: APPIdCATIQN FORy SANITATION PERMIT Permit No. ........ ..•-•-•••••• (Complete in Triplicate) .................. Date issued ..........................I..__.._...... -This Permit Expires 1 Year From Dote issued Application is hereby made to the San Joaquin local Health DistrictforOrdinance N rmit to construct and and existing Rulesand the work Regular oherein described. This application is made in compliance with County v .. �_..... . . CrZ• ..--...._...........CE .......................... JOB ADDRESS/LOCATION `... ... CENSUS TRACT Owner's Name ............. .......... . .............: ...••-•-- .........Phone ....... -'._ ...... City ...............................................----...• .................... . Address . y " r ..... .........Lcense # Phone 4 !1.......Contractor's Name ] Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ] Motel ❑Other ............................................ Number of living units....].------ Number of bedrooms .5.....Garbage Grinder ------------- Lot Size ------------------•..............-.. ........Private Water Supply: Public System and name .....................--------•....................... ...................:.............................. Character of soil to a depth of 3 feet. Sand 0 Silt❑ Clay ❑ Peat-❑`N Sandy`Loom ❑ Clay Loam ❑ ' 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, sewer is available within 200 #eetl SEPTIC TANK Size...................................' ' ' Liquid Depth PACKAGE TREATMENT [ � {.� ............ a No. Compartments Material ...................... Capacity ----•-•._...... ................ .Foundation .."Prop. Line ...................... Distance to nearest: Well -------------•••-• = LEACHING LINE No. of Lines _____ g . j Length of each line................-_ ..._...._ Total Length ...._---.................... _ 4 D' Box ........__'Type Filter Material --.Depth Filter Material .......................... ......... m ... Foundation ' Distance #o nearest: Well ..................... ...._...__...-•----..... Property Line ............... ........ F SEEPAGE PIT [ ] Depth Diameter .................Number .. ........................ Rock Filled Yes ❑ Na (� .,r Water Table De th ._._.....Rack Size ............................•- .........Foundation Prop. Line _........---•---...,_. Distance to nearest: Well .' --•'•"--'-"""•-" i REPAIR/ADDITION Prev. Sanitation Permit# Date .... ••---•......--••- " ) Septic Tank (Specify Requirements) ...... ........ ............. ...................................... _.__...._... - R Disposal Field (Specify Requirements) _.__._. :'•-- ...........................................•--••---...... -- • - - • • - -•--- --- --•-••-- --•-••----- ------------------...........-............................................. .......................................... - (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 iicen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed Owner ----------- --------- ------- . - try ....._ ._ . •• . Title . ---... . .................•- ._.... (Ifo r than owner) FOR DEPARTMENT USE ONLY DATE .. ....---- •- . APPLICATION AGC PIED BY ..... .. _ ....: . ... ..... - DATE BUILDING PERMIT ISSUED •--....---.........................-=•-.._......... -_.. _ -------- ----- ...... :..,................. --... ADDITIONAL COMMENTS ............... -....... --J..... . ........_ ..__..._....._... Date ... .... Final inspection by: ...:._.---•-- -- ----• ----• -- - -.. . SAN,JOAQUIN LOCAL.. HEALTH DISTRICT �. 4 7172 3 K