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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT pen" No. .......... ...... (CompletainTliplicate). ; .........---------- ................... This Permit Expires I year From Do#*Issued -Date Issued ......Y 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. 549 and existing Rules and Regulotions: JOB ADDRESS/LOCATION ............ *ENSUS TRACT .......................... Owner's Name ................ ..................... ...... .............Phoneo Address .................11:2 .......... ...... City ty Contractor's Nome - ----- - "I � D License# ......................... Phone ......... ag t.&_14..T Installation will serve: Residence)O Apartment House C3 Commercial oTraller Court Motel 0 Other................ Number of living units:--..I.... Number of bedrooms ........Lot size ........................... Water Supply: Public System and name ------------............ ............ ------ ........ .......................... ....................Privateyy kill Character of soil to a depth of 3 feet: Sand 0 Silt C10Y 0 Peat 0 Sandy Loom 0 Clay Loam Hardpan 0 Adobe 0Fill M6terla 1 ............ If yes,type............... .....I...... (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse sl&-) 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 --_----_---------------- Capacity ------------------ TYPO -------------------- Material-----------------_- No. Compartments .............. Distance. to nearest. Well --- .................................Foundation .................. Prop. Line .................... LEACHING LINE No. of Lines ............I----------- Length of each line.......•I................... 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 0 Water Table Depth ...Rock Size .... ..................... Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# --------- .............:........ Date I............... Septic Tank (Specify Requirements).......... .......... ........ Disposal Held (Specify Requirements) ...... .... ..................... .... ........ .......... ....... ............... ---------- ............. ------- ......... ----------------- ----------------------------------------- .. ... (DrawLeAsting and required addl on on reverse side) ........ I hereby certify that I have prepared this application and #ha# the work will be done in accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,,District. Nome owner or licen- sed agents signature certifies the follo Owing: i "I certify that in n the performance of the work for'which this perm.it is Issued, I shalt not employ any person In such manner as to becre subjeq_��'Warkma ' C tion laws of California." . . p i, __, )Workman's ompen!9 Signed ........... ---------- ------------ By --------------- --------------------- other than 0 r — ----------- ....... ........... _---------------- 0 I f t (If other than o r) ICOR DEPAR ENT USE ONLY 'N ACCEPTED BY ,M,j �, T -1-------------- APPLICATION ACCEPTED BY------- 0_ -C - ..-.-..__----•----------- ........... ........ DATE./- BUILDING PERMIT ISSUED ............. ....... -i- .......................................................DATE ................................... ADDITIONAL COMMENTS --------- ...............I..............__...... ...........------------ -------- ------------- .............................................. ------------- ------------ ------ -------- ---------- -------------------- 3��----*...... ----—----- Final Inspection by. - ......... --------- ------- EH13 2b 1-68 He------------ .. ...... .. ... . ........... ... .......... —Date ....... ........ •...... v. SAN JOAQ IN LOCAL EALTH DISTRIC8/74 3M