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FW OFFICE USE: APPLICATION FOR SANITATION PERMIT ....... .... a. Permit N ..... (Complete in Triplicate) I ............ ......... ---- Date Issued . .............. .................................... This Permit Expires I Year From Date Issued- Application is hereby made to the Son Joaquin Local Health District for a permit tio construct and install the work herein described. This application is ry?pde--...in .compliance with, County Ordinance No. 549 and existing Rules and Regulations- JOB ADDRESS/LOCATION . ...... ...... ------------------------ ------ ........CENSUS TRACT .......................... Owner's Name _17 4 . -- .... ----------------------------------- ........................ ............Phone ........... ........................ Address ............ .. ............I............ ----------- City . ... ..... ...................I......... �W��o Contractor's Name ..............--------- --..,-,License .... Phone Installation will serve. Residence;4 Apartment House,E] Commercial E]Trailer Court 0 Motel M Other .............._........................... Number of living units:...-.... Number of bedroornsJ?......Garbage Grinder AF... Lot Size ................... System and 'r WAAke I Water Supply. Public Sys name ...&Ak --------•.............................................Private El Character of soil to a depth of 3 feet: . Sand F] Silt 0 -Clay E) Peat E] Sandy Loom ❑ Clay Loom [J Hardpan ❑ Adobe Od Fill 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 SEPTIC TANK. Size--------------------------------_.............. Liquid Depth ... ...................... Capacity .. ...... -N6.-t Corn portments .................... Distance to nearest: Well . .------------------------------Foundation ............... Prop. Line ........... LEACHING LINE No. of Lines Length of each line. ..... Total Length .......................i._J/ '13' Box Type Filter Material --------------------Depth Filter Material ...................... -------_-------_- Distance to nearest, Well ........................ Foundation r.... .........- Property Line ...... SEEPAGE PIT Depth Diameter ................ Number .... ... .. ... ...... :;Rock Filled Yes C] No Water Table Depth ......... ....... ------ -------Rock Size .._..---•---- ------ D1 std_n-Ei_inearest:—Ve"il I—---------------- ............. F;o6nciatio' n.'.'_............ .... Prop. Line ............... ...... REPAIR/ADDITION(Prev. Sanitation Permit# ------------ ................... Date ----------------------------------1 Septic Tank (Specify Requirements) ... ........ --------------------I................................... Disposal Field (Specify Requirements) --- 0 ---------- .................. ------- Olt. --------------- ........... ....... ................ ..... ............ .............................-11----------------------- ...................... .. ............. ........ (Drdw existing and required addition on reverse side) I hereby certify hihcive prepared L'this 'application and th of the work w I be done in accordance with Son Joaquin County Ordinances', State Laws, and Rules'_and'Ite9uIatiin'Vof the Son Joaquin Local Health District. Home owner at licen- sed agents signs tune certifies the following: "I certify that in the performance of the work fol Which this permit is issued, I shall not employ any pe,rson in such manner as to become subject to Workman's Corn pen sationAaws of California." Signed ...... .... .. ......... Owner By . Title kk .. ............ ...... (if" than n owner r tha ()F0J110JPARTMENT USE ON Z? y APPLICATION ACCEPTED BY _ . .... ..... DATE BUILDING PERMIT ISSUED ........... ... .... ........ .. ..............DATE .. ........ ............... ADDITIONALCOMMENTS ............ -------------------------------- --- ...... _ ................. -----------............ ....... .......................... . . ......... --------------------- -------- . -----------C . . . ........... ... ..... ........................................... .......... . ....11J. .... ..... ................ ............. .......... ...... .. ......... .... ................ ... . . : . . . .. Final Inspection by: ......... ........ Date SAN .JOAOUIN LOCAL, EALTH DISTRICT 13 24, 7172 3 M