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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Triplicate) ................ ...... This Perrriit'Expires I Year From Date Issued Date Issued ......7S 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 Regulations: JOB ADDRESS/LOC AT ON ..� %...... .. -- - -. ...��........................................CENSUS TRACT .......................... Owner's Name .. ... .. ....... ...............,.....................................Phone Address . . ...... City ...�� ?e? - '........ Contractor's Name .__.. _...:. . - :. --��.L ,�; .......License # /17. �y Phone r Installation will serve: Residence [Apartment House Commercial ❑Traller Court Q Motelp Other.................... ....•.................. Number of living units:.._-....... Number of bedrooms -----..•----Gar6aga Grinder ..........:. Lot Size . Water Supply: Public System and name ................ .......Private ®J Character of soil to a depth of 3 feet: Sand n Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay loam ❑ Hardpan [? . Adobe 0 Fill Material ............ if yes,type ............... ............ (Plot plan, showing sire 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 TAMC Size................................................ Liquid Depth .............. Capacity -------------------- Type ---------_----.__. Material.............. ....... No. Compartments Distance. to nearest: Well ....................................Foundation ....................... Prop. Line .....................5' LEACHING LINE [ ] No. of Lines ---------- ------ Length of each line................----- Total Length ........d D' Box -----------. Type Filter Material .............. .Depth .Filter Material %P Distance to nearest: Well -------------- ------ Foundation ........................ Property Line ........................ � SEEPAGE PIT ( ] Depth ---- -------_------ .Diameter -------------_ Number ....... ----------------_- Rock Filled Yes ❑ No Q� Water Table Depth _... - .....................................Rock Size ................•-- w Distance to nearest: Well ...--•------------------------•.-------Foundation .................... Prop. Line --------...--...... REPAIR/ADDITION IPrev. Sanitation Permit# .--------------------------------___----- pate .................................. Septic Tank (Specify Requirements) ................................................•------...:............ ._... w ....... Disposal Field (Specify .. fes--••-•�- -----•• - F ,33"•�r 2�__._ -=---- ---•- ----- ------- - ---- ------ - - (Draw existing and required addition on reverse side) I' 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: , N 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 By .............. Title . (If other than owner) ------- 44 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .-........ �f _ - BUILDING PERMIT ISSUED --------------------------�---- _ - DATE ADDfT]ONAL COMMENTS --------------- --------------- •...................... ......_--DATE . ...-- ------------ ---------............................•--•-------------------------------------- ------------------------------------- .- .....-------•----.-...--•-----...--- •--------•------- -•------------------- � --.-..a.._...------ Y - Dte Final Inspection b ..... . .. .?.�.- EH 13 2L 1-68 lav• 5hSAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M