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�t S ' � FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ................................ (Complete in Triplicate) Permit No. ...7 ".� . ............. . . . This Permit Expires 1 Year From Date Issued Date Issued .......... ....... Application is hereby made to the Son Joaquin local Health District for a per to construct and Install the work herein described.This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulationsi JOB ADDRESS/L CMI Sf61....... .,. ........ .... .................CENSUS TRACT .... .. . ..... Owner's Name ... . . ., ........Phone.................................... Address ......... �. ........ . .. . City . ......................... ..... .... ... ... Contractor's Name .. . . ... ....r6/ . -..License # �,�,�'.��hone .............................. Installation will serve: Residence Apartment House 0 Commercial oTrallor Court Motel ❑Other............................................ Number of living units:......I... Number of bedrooms .....Garbage :Grinder ............ Lot Size ..................... ................ Water Supply: Public System and name ........................................ .. ... .......... Private [ '� Osorocter of soil to a depth of 3 feet: Sand E3 Silt❑ Clay ❑ int 0. Sandy laar+t :lam Q Hardpan❑ Adobe❑ 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 [ j SEPTIC TANK I j Size................................................ Liquid Depth ..... .... Capacity .................... Type .................... Material...... ........ No. Compartments .. ........ Distance to nearest: Well ........ ... ..... ...............Foundation ............ Prop. Line................... LEACHING LINE ( j No. of Lines ......... .::....... Length of each line.................. ....... Total Length ......................... 'D' Box ............ Type Filter Material ....................Depth Filter Material . ._....... .. ...... ................ Distance to neareste Well .... ...... Foundation ........................ Property line .... ...... (h SEEPAGE PIT [ j Depth .................... Diameter.. ............. Number ............................ Rode Filled Yes rJ No Q Water Table Depth ...................... .........................Rock Size ......... .. 17 Distance to neare - yi[611:_._....... ............... ......Foundation .................... Prop. line .. ........ REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. Septic Tank (Specify Requirements) .................... .....x. ................... ..... ................-........._ ..........._ .............. ... . .. Disposal Field (Spe fy Requirements) a ............................. .. ..- r..... . ... .... .... ... ...... .._... ....................................................... . ..... .............._..... ..... ....._.................................................. ......... . ......... ...... ... ..._.. __.. .. _..... (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that thei work will be done In accordance withfm Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District.Herm owner or bast- sed agents signatum certifies the followings "I certify that in the performance of the work for which this permit ii Issued, 1 shelf net employ any person In such maw as to become subject to Workman's Compensation laws of California." Signed . :. .. ... JOwner By _. -- (If other than owner) FOR DEPARTMENT USE' ONLY APPLICATION ACCEPTED BY ....... ...... ..... ... .. ........ . . DATE .... . BUILDING PERMIT ISSUED ... ........ ............... ... ... ......... .. ....DATE ........................................... ADDITIONAL COMMENTS........ . ......... ............I.............................. ..... ... ... ... .................................... .. .. Final Inspection by: . � `.................. ......._ .... . . .Date ., .. . ...:/..... .. .. SAN JOAQUIN :LOCAL HEALTH DISTRICT I �, E. H.3-3 241-'68 Rev. 5M 7/72 3 M