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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �C) -7 ... ..........I— (Complete in Triplicate! Permit No. ..�.�•./�---• .............. ................... Date Issued . .---.... 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: YrV ........,CENSUS TRACT .......................... JOB ADDRESS/LOCATI N . �..__.............. .-- .. .. ... ................�..... _ Owner's Name .... .. ._.. ....--------• -Phone --- ............I.......---- a ..... C Address ity �� a� ' �� _..._.._.. Phone ------------------------------ Contractor's Name .- _-- - - � �- License # .�.---.- --- Installation will serve: Residence p3-Aportment House 0 Commercial OTrailer Court -C] Motel ❑Other ...._- ---------• -- o f Number of living units:..../-...... Number of bedrooms . �te N Garbage Grinder ............ Lot Size .....�.c Water Supply: Public System and name ------------------- _... .... - lay Private [�]' Character of soil to a depth of 3 feet: Sand❑ Silt ❑ Clay ❑ Peat❑ Sandy LoamIay Loam �f 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.( NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK j ] Size.....___------------ •---•• ..... __ Liquid'Depth ............................It I Ca acit Type ------- -.------ Material— No. Compartments ----- I p Y . . Distance to nearest: Well .. . . ..-- ••-------------Foundation ........ Prop. Line ._-- ................. LEACHING LINE [ ] No. of Lines Length of each line .........-.-....... ...... Total Length ---------- 'D' Box .... .. Type Filter Material -----------.--------Depth Filter Material ..---------................•--•-_--•----••. Distance to nearest: Well .............•---------- Foundation ..... Property Line SEEPAGE PIT [ ] Depth Diameter ................ Number Rock Filled Yes ❑ No Water Table Depth .............. ......I---------Rock Size Distance to nearest: Well -------------------- -- - --------------F6-undation ..- --- -- Prop. Line ------------ ..•...... REPAIR/ADDITION IPrev. Sanitation Permit# ------- --:��---.- -----��> Date -- ------------- ) Septic Tank ISpecify Requirements) ..._ . .. -- ------- .......... -------------------------------------------------- Disposal ----------- -----•--------- _ .------.............. . __... .... .. ,y_ pisposal Field (Specify Requirements) ...- -- - a- � .:...._ ..... -------------__....-- ----------------------- ---- �. (Drdw 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 I as to become subject to W man's Compensation laws of California." Signed .:.. . ............ -------�-•------ - Owner �._ By .. . Title -. ...... (if other than owner) " FOR,,DEPARTMENT USE ONLY DATE �. APPLICATION ACCEPTED BY ... ....------... ..- ....�...-__...._. BUILDING PERMIT ISSUED -......__..._ -•..--- .................... ....... .. .... DATE . .._.....__ ADDITIONALCOMMENTS .... ------ ------ -------------------------------------_--- —.....__...... ...... --------- _ .. ---- ---------.•. ........ ....... . .. . . .. ..... ........ ........ 3 ` Final Inspection b •-----.Date -- ' ..._ SAN JOAQUIN LOCAL HEALTH-DISTRICT _ . 7_/723 ,