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-MR OFFICE USE: APPLICATION FOR SANITATION PERMIT N Permit o. ;Complete in Triplicate) Perm ..................... E ...........:.............................. ---------- This Permit Expires ? Year from Date Issued Date Issued /Q-(S•7s Application is hereby made to the San Joaquin local Health District for a permit to construct and Install the work herein describer!. This application is made in compliance with County Ordin ce No. 544 and existing Rules and Regulations: 148 ADDRESS/LOCATION .._..� .�-� CENSUS TRACT r........................ Owner's Name - ----- ------------ Phone-- - . .... ................ .......... Address r'��?. . ... ' . .....-------------•...._..._......Contractor's Name -.0109 ..........License # 3d0.V-V_9.. Phone $_7 .....P_......._ . ....'�d Installation will serve: Residence OfApartment House C] Commercial❑Trailer Court ❑ �- Motel ❑Other __....__.... Number of living units:_____ Number of bedrooms Garbage Grinder .. /e.sS Lot Size Water Supply: Public System and name Private Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loom 0 Clay Loam ❑ Hardpan 0 Adobe 0 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.) NEW INSTALLATION: (No septic tank or seepage pit ,permitted if public sewer Is available within 208 feet,) PACKAGE TREATMENT [ I SEPTIC TANK f } Size.......... .. Liquid Depth j Capacity --------------• ._. Type ------- ...-•• • Nomp $Distance. to nearest: Well ----___-- a Foundation -..... - - PopLine ..................... LEACHING LINE [ j ` a No. of Lines---------- . Length of each, line------------== --- Total Length 'D'. Box _11......-_. Type Filter Material .......... Depth Filter,Material t Distance to nearest: Well ............. -----_-- I=ovndation . --------------`_ .. xP►operty„Line. . SEEPAGE_ PIT [ ] Depth ...__f------ .:, Diameter ...---.......... Number ----------------------------- Rock Filled Yes ❑ No `F Water Table Depth p --.....Rock Size Distance to nearest: Well ........................................Foundation ..................... Prop. Line ..................... REPAIR/ADDITION{Prey. Sanitation'Permit+# ........I.............. ...___ Date ...................... Septic Tank (Specify Requirements) Dls osal Field - l� (Specify Requirements) ---- --• - - �• - - �• , .......__ �- --------•--•---------------------------•-•--- -----------••------- -----__................................... raw existing and required addition on reverse side) ! 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 Son Joaquin Local Health;District. Horne owner or licen- sed agents signature certifies the follpwing: d 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 ---------•�----------•-• Owner litlE BY (lf other than owner) FOR DEPARTMENT%USE ONLY - APPLICATION ACCEPTED BY ------- DATE --•- ----- -- BUILDING PERMIT ISSUED -_----. I -----------------•••--••-------•--------- ____ --_------------DATE -..------------•-- --- ADDITIONAL COMMENTS ---------------------------- - ----...:-_._.--_-. ------- -----------•----------------------------------------•---------- -----------•------------------------------------• ------------- ............................................ .--- ina inspection by: ---•-----------------------•- •-• •- -. ..._Date -��-1�:m J ....... EI•i 13 2h 3-bf3 Rev. �l - - - - . ._...-----...._....... _. SAN JOAQUIN LOCAL HEALTH DISTRICT $/7ji