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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT _" (Complete In Triplicate) ,. Permit No. .....—+ ' ................... ••-- ..................... This Permit Expires 1 Year From Date Issued Date Issued F 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 ADDRESS/LOCATION CENSUS TRACT Owner's Name ....... ��j _ r Phone.. Address ....__.....f`.._._ L•..r.... --------------- Cl Contractor's Name ty � ......... .................... ........... . _:__. !�.�-w��f..¢- "_" ;� ••-License #a��."J.-'��__ "•y• Phone . � _�_ Q Installation will serve. Residence ja Apartment House Commercial ❑Troller Court / ! Motel C3 Other -----------------•••••-------•- •-------•••- Number of living units:..__- Number of be rooms _ f r .___Garbage Grinder'. Lot Size .., _X�. Q Water Supply: Public System and name ...__ Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat El Sandy Loam ❑ Clay Loam C] _ Hardpan E] Adobe;X Fill Material ............ If yes, type ---- ----------------------- (Plot ------ -(Plot plan, showing size of lot, location of. system in relation to wells, buildings, etc, mutt be placed on reverse side.) \ NEW INSTALLATION: INo septic tank or seepage fpit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK f ze-_...... -•----••--------------------- Liquid Depth .............---- Capacity "--- _---._ Type •••"-".....---- Material----------- .......... No. Compartments Distance to nearest: Well ....................................Foundation -_.................._. Prop. Line ....... `` ..... Length of each line.__, LEACHING LINE � No. of Lines _.____1..-__• - " � t . . --�----•---....._. Total Length ....'.l'if......... 'D' Box .r--Q Type Filter Material Depth Filter Material _.(- ...... ................. Distance to nearest: WellFoundation ..._ f --••-• ��....-------- Property Line ............ SEEPAGE PIT Depth - - Diameter Number _ ....._.__.. ------ Rock Filled Yes k No 0 �1 Water Table Depth ...... ..... Rock Size .. . a :... ... Distance to nearest: Well •••-•-••Foundation _�� ----._....•------ Prop. Lisle .Ol.--..--•---.:...-- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- pate ) Septic Tank (Specify Requirements)_.___."____..._ _ •-- ---- •••'• .------------ me _ __ _ meDisposal Field (Specify a uirents) ---- .."-------- - -------- . ..............................................---------•-•.----.-"---•--- ---------•- •---................................... raw 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 � as to become subject to Workman's Compensation laws of California." P r an Y person in such manner Signed ....... ..... Owner By ........... ..:.r - Title _.__.._ (If other than owner) ------ -- ----"._._.._...---•.-.-...... FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ....._ . ._1 DATE ..... ... .7`... ... .... ..I ... .BUILDING BUILDING PERMIT ISSUED ................ " """" .. .. .. ............."---••-••-......•_•-----....__.._. --..........DATE ...---...._..........__. ADDITIONAL COMMENTS .................. • ......•--•-"• ••-----••-- .... •------•-•_.•--•----•---•...._•-•••-- Final Inspection by: .._Dat ...................... e .... . ..r ..��............. SAN JOAQUIN •LOCAL HEALTH DISTRICT' S E. H.13}24 1-'6S Rev. 5M