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FOR OFFICE USE: -4: APPLICATION FOR SANITATION PERMIT ............................ .....-_...... 3 _ (Complete in Triplicate) Permit No. .................................... f ---......... ------.-__-.... This Permit Expires 1 Yb ear From D Issued ate Issued /!J-_ :7-3 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 County Ordinance No, 544 and existing Rules and Regulations: JOB ADDRESS/LOCATION ..........�.7--'�.. ......L_ .........I..-..............CENSUS TRACT ........................ Owner's Name ................. '?~ LctjS.*.-i S!isKle,&f._............... _--------.............*._...............Phone ..41.6. Address ,- .............. . - ----- a 5 .!�� ._..._. -. :.: city Contractor's Name ..... R rsfi1-. .. _j_{ - ............._.._.._ ....License # �.1_3.'��z.._. Phone _ ... C��?7._.--_ Installation will serve: Residence % partment House❑ Commercial [:)Trailer Court 0 Motel ❑Other ............ Number of living units:...:(...... Number of bedrooms ...A...Garbage Grinder. ......._.--- Lot Size ...�'� d.l _... ........_... - - v Water Supply: Public System and name ....... .. ..Private ❑ w Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ll� 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[ I Size......................... Liquid Depth .-•._-------'.-- J 1 Capacity .. . .. ----- Type ,----- Material. s . .....•...._.. No. Compartments ...........:.......... .� 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 S Water Table Depth .. ......-......................................Rock Size ...................... ----•- Distance to nearest: Well .................:......................Foundation --,_ ------- Prop. Line .... ............ y� REPAIR/ADDITION(Prey. Sanitation Permit# --------------- --- Date .......--------........ ._- ._._ Septic Tank (Specify Requirements) ...................--------------------------------.--------- Disposal Field (Specify Requirements) ........ .. ._ -lam 2 r ........... . . .. .---............. -- ...... ......-_.............. ........... ................................. ........................ ---------- i (Draw 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 I County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health 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 issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." f Signed . .............. .. :. .... Owner - ...... ,. - -- ._.�. -------------- 8Y ----- --------� ---...,.. Title ...- � .. �-.-t ' (if other than owner) O DEP MENT USE ONLY APPLICATION ACCEPTED BY ... . . . .................... DATE BUILDING PERMIT ISSUED .... - ---------- .. _._...DATE . .. - ----•-•- ADDITIONAL COMMENTS .... .., . ........ .. • ....................... ...... ` ....... --------•-- .......... ------------.... ....... -- ...... ...... --------- •-•-•--------- ...... ............................................................. -------------------------------- - ------ •. -- . --- .................. :__,._ ..: .----- .---------- .... Oil Final Inspection by: ------ ---• ------- -----------••--------------- -------------- Date .. � �_71..._ . ... SAN JOAQUIN OCAL HEALTH DISTRICT E. H. 13 24 1-'68 Rev. 5M 7172 3 &H