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FOA OFFICE USE: APKICATiON FOR SANITATION PERMIT ..........k......... '............. : ............... 1Cotnplelbe in Triplicate) Permit No. ........ ...._..... 4 �! Thin Permit Expires 1 Year from Date Issas Date issued .3:-a :7L 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 ADDRfSSACICATION / { .....G .. ......................................cNsus TRACT .......................... Owner's Name _.... i`/ = 4� •• .......................... ........ .Phone . .. .. . - Address ........... 1 .... -C" � ......,.City Phone .......................... Contractor's Name •-- / � � x- ... .r...... License ill 1 � ..... Installation will serve: Residence[Apartment House❑ Commercial❑Trailer Court ❑ Motel❑Other............................................ Number of living units:......----- Number of bedrooms Garbage Grinder ...._._..... Lot Size ..1._"... ..-...... :�. .: Water Supply: Public System and name ............................... ❑- _. _......................................................... ..........Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat 0 Sandy Loam ay Loom ❑ Hardpan❑ Adobe❑ Fill Material ............if yes,type............... ............ (Piot plan, showing size 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 TANK f J Size................................................ Liquid Depth - Capacity .................... TYPO •----•-••••------•-• Material...................... No. Compartments .................... Distance to nearest: Well .Foundation Pr LEACHINGLINE [ J ...............................:... ._._.._._............. op. line .............,,....... � No. of Lines ........................ Length of each line................... ......... Total Length ............................ 6 'D' Box ............ Type Filter Material ....................Depth Fitter Material Distance to nearest: Well ........................ Foundation ........................ Property Line . __ _ . _...,, 0 SEEPAGE PIT [ J Depth _______ ___________ Diameter ..... Number _.._....._. ................ Rock Filled Yes [I No ❑ Water Table Depth ................................................Rock Size 17 Distance to nearest: Well ........................................Foundation ...... Prop. Line ., ... ...9 REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ...........____.._._.._......._,j t- Septic Tank (Specify Requirements) ............................... ........................ ...... Disposal Field (Specify Requirements) --. .. . . _... - ..... _ 0 _. =................ ......... ..c ................................................ ---- (Draw existing and required addition on reverse side) 1 hereby certify that 1 have prepared this application and that the work will be done In accordance with son Joeq"VM. County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,DisMct. Nome owner or litew 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 Callfornia." Signed --------------- ---------------- . Owner BY �Z� .._ C�` . 3itle JR4? -f�� ►. w_ Of other than owner) -- = -------------------------••--•--•-•-•--•- f0 EP ARTMENT USE ONLY APPLICATION ACCEPTED BY__.... .-_ G- BUILDING PERMIT ISSUED --.--• DATE - -_ 22�._....••_... ADDITIONAL COMMENTS ............... .............................---•-...-------•...-----...•--........_DATE •----................ - - y: ..---............... .. .. ............................ -...-..__._..._._.._...-------- --- ....------. ----... .._.. .---._........... ............. �% ...-•---- ---•-- - - --•- -- --.._ - - - - - .............Date._..:.............. •. --• •.......... ..................................... ------- Final Inspection b �• •-•-- EH 13 2jt 1-68 Rev. 5M ._ .._._._. . �/ 6................. SAN JOAQUIN LOCAL HEALTH DISTRICT ?Jt 3M T