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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Co`rnplete in Triplicate) _. Permit No. ._.-...-....... ............... .......................................... ThisPermit Expires t Year Frorn 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 Ordinance No. 544 and existing Rules.and Regulations: JOB ADDRESS/LOCATIO ..p�..�,�. }@1.s.......PC7P�. ................................................CENSUS TRACT .......................... Owner's Name ... ... ::'.... . ..... C', .._. one ....Ph .�...,. . . ..... Address _ ` .. . lI.. _ .�. .... ........_•.......City ... ............ .. Contractor's Nome ................... ......... .. . . .. .......................License #,7-> / ?��}.�j.__ Phone Installation will serve: Residence Apartment House] Commercial❑Trailer Court r] Motel ❑Other �---�-; Number of livingunits.....( Number of bedrooms 3 Garbage Grinder g Lot Size ...... ................. .......... ....... Water Supply: Public System and name .....................................................................---......................................Private I Character of soil to a depth of 3 feet, Sand E] Slit El Clay 0 Past❑ Sandy loam❑ Gay Loam ❑ Hardpan❑ Adobe Fill Materfal ............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 INSTALLATIONS (No septic tank or seepage pit perrnitted if public sewer Is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK{ ] Liquid Depth .............:..:..... [ Size...... ....... ... Capacity ................... Type .................... Material...................... No. Compartments ............I......... Distance to nearest: Well ....................................Foundation ._..._... ............ Prop. Line.................... � LEACHING LINE [ I 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 [ j Depth Diameter ................ Number ...---.s...._.............. Rock Filled Yes ❑ No ` , _i Water Table Depth ..Rock Size .................. Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... REPAIR/ADDITION IPrev. Sanitation Permit# .......... .. ....................6S ate _.U-t�......._....__.....) Septic Tank (Specify Requirements).-...'...,.. ._.._ '4 �/.. .. ----•-----..............._.................77 t �� ... Disposal Field (Specify Requirements) .... ... ..... . ......_ 4_... ...._._...._......._..._.._........... ......................... ........................... ....... -- ................. ........_......._.............------------------............. ......... (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 JaoquIn County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health Dlstrict. Nome owner or Ilcew sed agents signature certifies'the following: - "I certify that in the performance of the work for which this permit Is issued, l shall not employ any person in such nsanner _as to become subject to Workman's Compensation laws of California.',' Signed ................ .---•---. Owner . -------•- --- . .................... Title . - By -- _............._.._..... (If other th o nerl FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ... __-_•---_-• 2... / ..._._. ----•-•:----•----•---....._..._. DATE /.. .• ...•`�-•-- •-- •� ---.�?....._: BUILDING PERMIT ISSUED ..................................................................................................._..........DATE ................ ..................... ADDITIONAL COMMENTS ................ ........................ --------------- --------- ..............................-.............-------.........,........................... ............................................. ........................... .._ ...................... Final Inspection by.. + !Z' ....... .............•--•-------.-....................... ..._.._ Date �.. _. ... '- EH 13 2>~a 1-68lieu. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M I�