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POR OFFICE USE- PPLI;ATION FOR SANITATION PERMIT Permit No ..'._ '_- 3 ;Complete in Triplicate) -- - - This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin local Health District for a permit to construct and install the work hereir described. This application is made in compliance with County Ordinance No. 549 and existing Rules nd Reg 'I t* P/ ATION �° � ,r.. Ldlx;a .. ��s r �ICENSUS TR 'CTS-------------------- ------ JOB JOB ADDRESS/LOC- ✓_177 �2 f _ : .._ - Phone Owner's Name Address - � - --------- City J 7 Contractor's Name ------..-------...... - -- -------- _._-.. License # 7 X. -- -- Phone Installation will serve: Residence [Z-Apartment House'❑ Commercial [7]Trailer Court .❑ MotelX❑ Other Number of livingunits: Number of bedrooms a _ '� .-.--Garbage Grinder ->'�Vic'. 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 ❑ Adobe ❑ Fill Material _.--- If yes, type ---------_----------------- (Plot _-_.__..__.--.-_----._(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) O. ` NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) L14 PACKAGE TREATMENT SEPTIC TANK Size �7° - - ;----- Liquid Depth . Capacity/,Zell?e�._-.. Type -��,- Material- - -ew_ d, No. Compartments __.- -_._.--. s : Distance to nearest: Wel ----_�.V___________________Foundation --/� __.___._-- Prop. Line _- ------- _ . LEACHING LINE [' ' No. of Lines ------�Z------------- Length of each line--- Total Length __ -------------- D' Sox y -/c __ Type Filter Material /A_Depth Filter Material '______________ Distance to nearest: Well _115L97_1---------- A -_____-__ Foundation '-_._ _ . Property Line _______________ � F7 r ori SEEPAGE PIT [�f Depth A- -- Diameter ________ r ________._- Rock Filled YesX No ' ` p � ,,�=� Number - - - = --- � Water Table Depth ____-._ __� Rock Size / wnL ----------------- Distance -------------------- ----- -------- - ---------- - Distance to nearest: Well .___yIf_/' ._-_________--._-Foundation '-�' _f__-- Prop. Line -_------------------- REPAIR/ADDITION ______-______REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------- Date ---------------------------------) Septic Tank (Specify Requirements) - ------ ---------- --------- -----------------------------------------------------------•----------------•----------------------------- Disposal Field (Specify Requirements) ------------------------------------------------------- -------------------------------- -- ----- ------------ ---- --- - ---- --- - ------. .- --- - -------- -- - ----- - -------------------------------------------------------------------------- ------------- --------...- ---- ------ -- ------- ------ --------------- ----- ------ ------ - --------------------------------------------------------------------------- ----------------------------- . ... - . . ------ (Draw existing and required addition on reverse side) 1 hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Lays, and Rules and Regulations of the Son Joaquin Local Health District. Some owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not errataloa any person in such manner •� as to become subject to Workman's Compensation Imus of California." Signed . _ - -- - - Owner r - - Title . ------------------------------- By ------ -- ------ -------------- '` other than owner FOR DEPARTMENT tJ5 ONLY APPLICATION ACCEPTED BY ....... .1"��_- --._ ^ ------- -------- DATE .... '- - -- ---------- BUiLDINGPERMIT ISSUED ------- ------------- ------ - ------ - --•-----= ..._.... ....... ..----- ----•---------DATE - ---------------------------------------- ADDITIONAL ------- •---- •-------.ADDITIONAL COMMENTS _._-. - . ----- : --- . --- ------ --- Final Inspection by: . -- Date SAN JOAQUIN LOCAL HEALTH DISTRIC- G Li C ':LR O_., hs