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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) i' ................... Date Issued ..'7.. _/. ..7 . ...........................I............_. h - Y This Permit Expiree`l.Year Frofrr Date�l'ssued` / Application is hereby made to the San Joaquin Loco) Health District for a permit to -construct and install the work herein described. This application4-made in compliance with County Ordinance No. 544 and existing Rules and Regulations: JOB ADDRE5S/LOCATION ..._;h... '=1c�`'`�r...................... ................ CENSUS TRACT ..........,...... r � '.... Y Owner's Name1_ •1:1 1........:......... 1 ...........1,111..... ........... ...Phone..................................... --1.11 Address .......Ns;�P . ....................................................... city City .._�.._._...._ . Contractor's Name '........................................License.# .... Phone Installation will serve: Residence;@ Apartment House❑ Commercial-'(]Trailer Court ❑ Mate) ❑Other ....................................... .... Number of living units:... .... Number of bedrooms L? Garbage Grinder IVP__ Lot Size M4.74&074A..................... Water Supply: Public System and name ....................................... .................................................Privoteg Character of soil to a depth of 3 feet: Sand❑ . Silt❑ Clay ❑ ' Feat❑ Sandy Loam 0 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.) PACKAGE 'TREATMENT ( ] SEPT tank or seepage pit permitted- if public sewer is available within 200 feet,) �� NEW INSTALLATION: (No septic F IC TANK Size. .��; ..e �" r�' ..`. liquid Depth .. ' � { Capacity �...... Type _... Material.�i/1.�..... No. Compartments ........ ' Distance to nearest: Well T T•. + �-- Foundation :.- _...- -- -----•--•---•-----._ kf.�----------- Prop. Line LEACHING LINE No. of Lines ..... Length of each line.. 'd... Total Length � x __. .._._-�-_. •. .. ........................... ...........-........: ..`... .Y:.. .:.... . _I/0.. Type Filter Material 60114.6_..Depth Filter Material Distance to nearest: Well .%;:t._4f Foundation ......... Property Llne ...S...... S Depth .......... GtSgMr � , Number .------ Rock Filled, Ye&-qg NoC Water Table Depth .;?— Rock Size # . nearest•�W. ell ._._.. --::- � ,....Foundation �T`�. - Prop. Line C ............ REPAIR/ADDITION(Prev. Sanitation Distance to Permit#�--••---•1111.-•-- ---....................... Date -•--•---•-•-••----•-•--------•--•-) •-, Septic Tank (Specify Requirements) ..............:.. ..----------• -• ............................................... .........•........._............................. ,.� 1111. ��..mw. Disposal Field (Specify Requirements( -------------------------------------•-•--------------•------•---•--.......................-•-.---•---•---... ----• .......................... . .-••....-----•-------•-....._...--------......-----•--._...-----•--•--•---....__........_....._...._................._..._......_.................. der .(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 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 employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ...1111.- ..... Owner ---------1 111.._._11.11..-•--------------••--•-• ,� y-+ BY 1. . . . ............ Title ...c% i:5�_ .................................. Cher than owner) FOR-DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- ................................................... DATE ... =,l ---------- BUILDING PERMIT ISSUED , .. ......................... ---..._.. ..................... :.. DATE .. . .----••......................•--..... ADDITIONAL COMMENTS _... ............. .. .• °, --1111 , --------1111-................................. ...................................................... -• •... .......... . -------------•----...... --.....__..... - ••... --- -----•--••••---••- ................. ................... .. . .......................................• • ••... ........ ----•-- ..........I........................................................ Final Inspection by: ............ ....Date .� - -, ............. SAN JOAQUIN -LOCAL' HEALTH DISTRICT 'E.- H.13 24 V68 Rev. 5M 7/723.,4