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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ..................... Date Issues 5C? .......................................................... This Permit Expires 1 Year From Date issued ...._.........•.--•- 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. I JOB ADDRESS/LOCATION ......../.. ,. .,- �/ C .. . .,e.� ..... Xr........ ...... ..... NSt15 TRACTOwner's Name � -�... _ .......................... Address .................... ... ..._............ ......... ... hone ,. .:.. . ' City .......... �. Contractor's Nome . /� ••� ... ... _. .._.... ,. 2_rra -it.Lfcense # .a2J:2 /.2''p_. Phone . Installation will serve: Residence Apartment House 0 Commercial ❑Trailer Court ❑ Motel ❑Other ........................... --.........................:.. Number of living Number of bedrooms ...;—.. ..Garbage units:..... ...._. Grinder C- -Lot Size /... ... ....... Water Supply.. Public System and name ,o ®' . ... .- -- ---... ..__ ----•--•-•--•........ ..........•--•---......Private ❑ Character of soil to a depth of 3 feet: Sand❑ . Silt❑ Clay ❑ . Peat 0 Sandy Loam 0 Clay Loam ❑ Hardpan ❑ Adobe A Fill Material .......... If yes,type ........................... { 1 (Plot pian, showing size of lot, location of. system In relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATIONS (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT��[-]� SEPTIC AN i } L=X l S r 1 Size.....-- Liquid Depth G ;�4ype .......f............... 6- jNo. Compartments Capacity .- . Material //�� L✓ tN •-----....... lam...... .... Distance to nearest: Well .............. ....._ ..Foundation ...................... Prop Line LEACHING LINE ( No. of Lines ...I . ......._ ........... Length of each line.---••-e7.C.q. ........ Total Length 'D' Box l_-. Type Filter Material ......Depth Filter Materialc /9- ............................. Distance to nearest: Well �71r.. ._.-e- "C. 4 � Foundation f...................... Property Line ..SS..... � .. SEEPAGE PIT LK Depth ......... -Diameterf Number .... ... ............... Rock. Filled Yes ft No ❑ Water Table Depth ---....... .�.�.................... .....Rock Size ...................... Distance to nearest: Well ...... ?�`:--- -1rr'-..Foundation ..f Prop. Line ......_ REPAIR/ADDITION(Prev. Sanitation Permit# ......................... ...... Date r Septic Tank (Specify Requirements) ............................ ....................... .............. ............ ............._................. Disposal Field (SpecifyRequirements) ` r .�-�-� .... ....:........ ...............................................................................,......---------••....... _ (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 r as to become subject to Workman's Compensation laws of California." Signed .......... Owner By ........... -�.,..�:.lP` .. Title (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION. ACCEPTED BY .... ... .... BUILDING PERMIT ISSUED DATE .-- --...• ...: ........DATE . ADDITIONAL COMMENTS ....... 7. ........... .............. ..............................••--• ....................................................................................................................... _�.........._ ..�................................-----.............:• _:... ..............: .............. ............. .... _.. ........................................ .. ... ....: _. - . -•-•............ . . .. .. Final Inspection by: f � ......• - .... ....... .. .. ...... .. .............................:.................. ........Date .............. SAN JOAQUIN LOCAL HEALTH DISTRICT } E. H. 13 241.'68 Rev. 5M 7177 4 " ..� — _ .M