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FOR OFFICE USE: ' APPLICATION FOR SANITATION PERMIT 77 !Complete In Triplicate) Permit No. .............•._.... ......................................................... This Permit Expires t Year From Date Issued -Date Issued •�: - 7 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/LOCATION ....�.�� . . •• ..... • ........ ..CENSUS TRAGI' Owner's Name /1�.._.. , APhone ..........•............... Address V... . x._ �/C/ . ..... City....... Contractor's Name . .. - - - �...... . ....... ...... ........ -- - -...........License # . . Phone ..............•............... Installation will. serve: Residence Q Apartment House{] Commercial ❑Trailer Court Motel [�Other ............................................ Number of living units:. ..... Number of bedrooms Garbage Grinder Lot Size .-..---- Water Supply: Public Sy m and name ............. ...Private ❑ Character of soil too depth of 3 feet: Sand❑ Silt[3 Clay 0 Peat❑ Sandy Loam ff Clay Loam ❑ Hardpan j] Adobe D Fill Material ............ If yes,type............... ............ (Piot 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 f I Size................................................ Liquid Depth Capacity --••---------------- Type .................... Material...................... No. Compartments Distance. to nearest: Well ----------------- . .........4 ----- ........Foundation ...... Prop. Line LEACHING LINE [ j No. of Lines _._-.-____............. Length of eachline................._......_-... Total Length 'D' Box ............. Type Filter Material ....................Depth Filter Material Distance to nearest; Well ........................ Foundation ........................ Property Line ........................ SEEPAGE PIT [ j Depth ----------------_-- Diameter .------------.- Number ........._..._._............ Rock Filled Yes ❑ No 0 Water Table Depth ................................................Rock Size •-------- ...................... Distance to newest: Well ........................................Foundation •................... Prop. Line ...................... REPAIR DDITION(Prov. Sanitation. Permit# . Date Septic Tank {Specify Requirements) ....._....................................•--_--•--........... Disposal Field (Specify Requirements) ............ ................ ........ ............................ --------------------------------- ----- --- �.----•• ' � X Z (Draw existingand required ad tion on reve a 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 e---• --...w 1.- -f__...r.- ��Jitle --- �..................... . . (i other-than owner) FOR DEPARTMENT. USE ONLY APPLICATION ACCEPTED BY -----G._-- ------------- - ---------"---- DATE .51 ,:.---- -- BUILDING PERMIT ISSUED ------- --...- _.. --------- ----------------------DATE ADDITIONAL COMMENTS ------------ ...... --------- ................ -•-•••---•-•----••----...----•-=---•------ -••---------•-•--------•----._...---•- ------- Final Inspection by: ------------- --F-- Date 2 2 _.._._....... .-- - ----- -. ..-•--- ................_...---•--------------••-------•------- •_ .... 13 2!� 1-613 Rev. 5M AN JOAQUIN LOCAL HEALTH DISTRICT 8/7It 3M