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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT S- ....1�1.:--/...t. ............... ...._�..�j. .. (Complete in Triplicate) Permit No. ...7 � .......... 4.� j This Permit Expires 1 Year From Date Issued Date Issued ! ..3•'lS. 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 mode in compliance pwith County Ordinance No. 544 and existing Rules and Regulations: JOB ADDRESS/LOCATiOY1... Q._f (,.. ....... . .----- .._.....CENSUS TRACT .—.......--•... ............ Owner's Name � �-• Q� .. . ...........................Phone ..........,. Address _.. .6. .-. ��ql City .._._ Contractor's Name __.. _... ..., ..._._ ~_ .. 6" .............._..License #!1 :3 3 .... Phone r ��gv�0.7. . . Installation will serve: Residence)<Apartment House❑ Commercial ❑Troiler Court 0 Motel ❑Other . .. . .. ......-- _................... Number of living units:_ ._.. . Number of bedrooms ..........Garbage Grinder Lot Size ... .................. Water Supply: Public System and name . .. ._ -------------......__.......... -........ ...................................___...............Private$ Character,of soil to a depth of 3 feet: Sand❑ Silt[-1 Clay ❑ Peat❑ Sandy Loam [] Clay Loam 0 Hardpan ❑ Adobe X Fill Material ..,. . ..... If yes,type ....._. _.. . (Plot plan, showing size of lot, location oT 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,) QV•` PACKAGE TREATMENT [ } SEPTIC TANK j ) Size.... ................... .. Liquid Depth _.........................V' Capacity _ Type ---- Material._-._. . . _. No. Compartments ......................� Distance to nearest: Wel( ...........Foundation ....._...... ....... Prop. Line ....._._..........._.. LEACHING LINE No. of Lines l __ .... Total Length ._...._. [ ] _ - Ltr►gth--of eachline .._. ,_ . ................ 'D' Box Type Filter Material ....................Depth Filter-Materlafi- '.. _ ._.:.-------.....--_-.--•---_-. Distance to nearest: Wel) .-- ------ ........ Foundation .._._._.. .Property .line ........................ SEEPAGE PIT [ ) Depth .__. Diameter ............... Number Rock Filled Yes 0 No Water Table Depth .. ......................___..__._....... •_..Rocl 3 ie ,................ ,_ ._ Distance to nearest: Well ... .......... .....Foundation ..... ... .. Prop. Line ............... REPAIR/ADDITION(Prev. Sanitation Permit# ___._._ ------ ...... ..... Date .............................. ..) I? Septic Tank (Specify Requirements) , _ . . . .. . . .. .......... ...... ........... . ................. Disposal Field (Specify Requirements) ----..._L l� ... Qy'__. .. ........ .... M� /// _...._._................. .....-...... ... ..... ._.. _...................._.__.... ...................... ......-..._--.-... ....,..-..._._....--------............ . (Draw existing and required addition on reverse side) I hereby certify that I have prepared'this application and that the workwill be d e in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulofions of the-San•Joaquin LocalMalth-District. Nome owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is 6sue&, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed By . - ..... . ..... ........ --.... Owner - _ Title J(If4er than owner) R D RTMENT USE ONLY APPLICATION ACCEPTED BY . _ DATE . -R /sem BUILDING PERMIT ISSUED ...- , _. DATE . ............. ADDITIONAL COMMENTS ...... • -- --- ------ --- _ . . .. _ . _ .............._......... ----------- ............. _ Final Inspection by: ....._. . ........ . .......Date ._.. SA JOAQUIN LOCAL HEALTH DISTRICT 13 24 E. H. 1-'68 Rev. 5M ___._7/723X