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FOR OFFICE USE. APPLICATION FOR SANITATIONPERMIT ...... ............_....................._..........__.... . #Complete in Triplicate] .......... ................... Permit Na. .............................................. This Permit Expires ] Year From Date Issued Date Issued Application is hereby made to the Son 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/LOCATI ..... .. .� _.3 ' _._ .. ------- -•- . TRACT Owner's Name .....' Phone Address _..._.....__.._ .. u City .........1� ......... . . Contractor's Nome _::. .. . . �_.... ...... = -- ----- - ------•----.:.License# >'Pkone .............................. I Installation will serve:. Residence—EM"Apartment House f] Commercial ❑Trailer Court ❑: Number of bedrooms __�-----Garbage Motel E]Other --------------------------- Number of living units ....... �- - 9e Grinder :.-----,---- Lot Size Water Supply: Public Systein and n ame ..---•-- --------------------------------------------------- •---- .--_.-•--- --------Private ' Character of soil to a depth of 3 feet, Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ '� iHo dpon Adobe ❑ Fill Material ............ If yes,type .............................. (Plot plan, showing size of lot, location ofsyktem4in relation to wells, buildings, etc..;must be placed;...on reverse side.) NEW INSTALLATION: I (No septic tank or seepage pit permitted if sewer.is avollable,within 200 feet,) PACKAGE TREATMENT [ SEPTIC TANK f j Siae..................... .................... Liquid Depth .................... . ._..s Capacity F'................. Material...:.......... No.' Compartments 3 .Foundation Distance to nearest: Well Prop. Line ....::............. .............. ... LEACHING LINE [ j No. of lines ----------------- -=-+Len th�of,each line-----..-_.:_•__ Total Length .._,_:...... DBox 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.. ---.....--.......................-.--... .Rbck Size ..... •............. Distance to.nearest. Well _--:---•-------.-__- ---------------Foundation _...._._.._._..-•-:. Prop Line;......:.-----: I . REPAIR/ADDITION(Prev. Sanitation Permit# _....__.........................-----_..•__ Date ----___......._..._.___-__ ....... Septic Tank (Specify.Requirements! ...... ----• = ................. Disposal Field (Specify_ Requirements} '__`:_-. ......_L................ ., t ... ..... --•------------•- ...................... ,.Q •F (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 County Ordinances, State Laws, arid' Rules and Regulations of the San Joaquin Local Health'District. Nome owner or licen- sed agents signature certifies the following- "V certify that in the performance of the work for which this permit is issued,'1 shall not employ any person in such manner as to become subject to Workman's Compensation laws,af-California. Signed __........-- n .. w erg, By.................. (If other than her) = :.. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . . ............ .............:...........•--------=-....:-_-_..:_ DATE ffj.'- y .... BUILDING PERMIT ISSUED .:._.•----•-=--->::__. - ..DATE ADDITIONAL COMMENTS ; :........... .......... ......................................... :. :......::........... ..........I............. a Final Inspection ...--- •. ...... a..... . ---- - ......- ... -7. ....... ...._. P Y Datef -! . .... ... .... ' r _SAN JOAQUIN LOCAL,HEALTH'.DISTRICT E. H.I.3 24 1-'68 Rev- 5M 7/-7 Z u