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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ...... .........r..._...._. ........ (Complete in Triplicate) _.............� ........ E i 376 .............................. This Permit Expires 7 Year From Date Issued 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 brdi`nance No. 544 and existing Rules and Regulations: JOB ADDRESS/LOC TION .... Il..-__. ... F-�Q -.� r -------------•� ............CENSUS TRACT ..-------••--... .__..... Owner's Name ---..........--=- •---.._... _..Phone .................................... Address . .11 •--•-•. City -•�•5 ... .--- Contractor's Name .6-y�.......S�rz "L��a� - •---------------------License # ? - -- Phone : .:......3 .. Installation will serve: Residence ff4artment House❑ Commercial.❑Trailer Court Motel [].Other ------------ ----------------------- Number of living units:............ Number of bedrooms ..- ..Garbage Grinder ------------- Lot Size _.. .................... Water Supply: Public System and name ------------------------------ •----...------......------............ ----------------------------------------Private I� Character of soil to a depth of 3 feet: Sand n Silt❑ Gay ❑ Peat❑ Sandy loom .0 Clay Loam ❑ Hardpan ❑ Adobe �Ill Material _.. ........ If yes,type ............................. lPlot 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 TAMC'[ ] Size.........-...............................-....... Liquid Depth .......................... � 'J Capacity .................... Type .................... Material----- ................ No. Compartments ._..... .............. Distance to nearest: Well ..:::.._._.Foundation ...................... Prop. Line ...................... LEACHING LINE [ ] No. of Lines ........................ Length of each line---------I——............... Total Length ............................ 'D' Box . Type Filter Material ._Depth Filter Material Distance to nearest:.Well ------------------------ Foundation ........................ Property Line ....................... SEEPAGE PIT O Depth Diameter ................ Number ............................ Rock Filled Yes ❑ No ..Rock Size • Water Table Depth_- •r=--•--•-----------}-------• -----.......----------•-•-----•- --.. Distance to nearest: Well .....................•...................Foundation .................... Prop. Line ................. REPAIR/ADDITION(Prev. Sanitation Permit g ..........................•-.•------------__ Date ............. ----.-_-----------•) Septic. Tank (Specify Requirements) ... ..................................----- --.. ..........................---•--••-------........_�..-..---. ••--........... Disposal Field (Specify Requirements) r Q • 1,�yf--------t.. u. .............................--------- ---------------------------------------- ----.._-...-----------------•------------......._.---------------•.....--------._...... ------............__............ (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, 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 as to become subject to Workman's Compensation laws of California." Signed .__._.... -•-- --- --- ---- -------------------------•••-•-...------_.. Owner ,r� p Title C�G �G ._.�... e1l�' By !-._ .. .-------------------------•---..................... . .-. ........... other than owner FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY ...-----_!4C ......... ... ................................................................_•-....... DATE ........ ..fs. ..... ......... BUILDINGPERMIT ISSUED ................... -•----•-- ...........-................._ ......................._DATE ._.....__.. ............................... ADDITIONALCOMMENTS .._..----•-•••...................... ----._......---••---•----....._...........----...._..---.....---•----....._..........------•-• ...................... ........... ......................................... .... .......... .........................................._.. '...... -. __... f .... ...__.......J ...•----•Date ..... [�•- Final Inspection by. 1Y� 9. SAN JOAQUIN LOCAL ALTH DISTRICT E. H. 1-3 24 1.'68 Rev, 5M _. _� _. _ 7172 3