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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. . - •••••• r............................... (Complete in Triplicate} ....,� _ Rate issued .6-i S:•-7.6 ._.-J,�.._ .,........ This Permit Expires 1 Year from Date Issued .............. Application is hereby made to the San Joaquin Local Health District for .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 LO ;`O�N. .�•-� .`..,.r. ..�. a.1L,.�?��-•....1...... _.._' _.__�.". ... +.......�..�..�.,...,.�.c. CENSUS ..T_ .R.ACT Phone .................................... Owner's Name -- ........../.� Vie.. ....... ........ Address ..- ..�,.A09Q_G. 61................................City ....................................... ............License # � -•-- Phone . Contractor's Name installation will serve: Residence 23,Xpartment House fl Commercial oTralier Court 0 Motel ❑•Other............................................ oms ... . �..Garba a Grinder Lot Size ... ��' ............ Number of living units:............ Number of be ro .f�. Private Water Supply: Public System and name ............................................. Choracter of soil too depth of 3 feet: Sand n Silt❑ Clay ❑ Peat❑ Sandy Loam-[j Clay Loam Q Hardpan❑ Adobe g3�Flll 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 [ I SEPTIC TANK, ] Size.......................................... .•-- Liquid Depthe Capacity .................... Type ---------_--•------ Materwl.._......_... 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 ........................ Depth Diameter . Number ....-....................... Rock Filled Yes Q No Q SEEPAGE PIT [ j .................. � -J---......... -------------------Roc Size •-•-..........,.................. • Water Table Depth-_!...........�.----.-.------ --� Distance to nearest: Well .Foundation Prop. Line ...................... """""""""--'" REPAIR/ADDITION Prev. Sanitation Permit# ............................................ Date ---------------------------------- Septic •--- - -Septic Tank (Specify Requirements) ...................... 9 ............. Disposal Field (Specify Requirements) G-Q 4.r' `'`" YC "" "" _..._._ .......................................................... ---__ - - --• . - - ..--•---•..........................• ................... -•-- -••--•-•-•---•---..............................I........................ (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that the work wail be done in accordance with Son 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: permit is issued, I shall not atnploy any person in such manner "I certify that in the performance of the work for which this p as to become subject to Workman's Compensation laws of Califorhlb-" Signed . .......--•---•---.._...: Owner ✓ � c� .......... .. .............. ... l'. . /� c.... Title CQ �C' '`''.__'..._".' other than owner FOR DEPARTMENT USE ONLY DATE C /S ...? .......... ....... ......... APPLICATION ACCEPTE�BY ......................................'. ......._..... DATEBUlLDlNG PERMIT ISSU ................ ................................. ADDITIONAL COMMENTS ........................................•----.._.........---- ..................... ........................:._.._....:....:.. .........................._ .............................. . „_.-------• :- ...: = :L✓!' ........:Date I ins ection b SAN JOAQUIN LOCAL ALTH DISTRICT w, 7/723 .-.,- E. /723E. H.1-3 241.'68 Rev. 5M _ .