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r FOR OFFICE USE: 2-.%3-b ' VuW 1 APPLICATION FOR SANITATION PERMIT ..........I......................................... (Complete In Triplicate) Permit No. ..................... •........:.•.............•............. This Permit Expires t Year From Date Issued Date Issued ... � Application is hereby made to the Son Joaquin Local Health District for a permit to construct and instal) the work herein described. This application is made in compliance with Cou ty r ' once No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ..... `. ` _.. �..-- .....................CENSUS TRACT ..... Owner's Name . . . . . . 1../....,_A,-.�- Phone . ...,... .. ......... .........,, Address t�-L ..........City .. ..... . �j /f Contractor's Name ._... / -?Vr-e .. . ................License ih .. - .1-oPhone Installation will serve: Residence P§Apartment Hou Q Commercial❑Trailer Court r] Number of living uniMotel ❑Other........................................... ts:..._. ..,._ Number of bedrooms ............Garbage Grinder ............ Lot Size .F•�.�:'.�............................ Water Supply: Public System and name ............... .....................................................Private❑ Character of soil to a depth of 3 feet: Sand D Silt❑ Clay ❑ Peat❑ Sandy Loam Q Clay Loam„j3\ Hardpan❑ Adobe 0 Fill Material ............ If yes,type............... ............ (Piot 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{ ] S!ze................................................ Liquid Depth ..........................� Capacity ---------- --------• Type ..---. ............. Material...................... No. Compartments ......................0 Distance to nearest: Well ....................................Foundation ...................... Prop. Line ........�.,..........5 LEACHING LINE [ ] No. of Lines ------/--------------- Length of each line..._ .0 J....... ..... Total length ...�.�...............� 'D' Box ......-..... Type Filter Material ....................Depth Filter Material ............................................ Distance to nearest: Well ........................ Foundation .... ................... Property Line ........................ SEEPAGE PIT [ j Depth . .. /�Diameter ................ Number .......,(..../................. Rock Filled Yes ❑ No i❑ --� 0 WaterTable Depth ................................................ Rock Size ................................ �6 Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... -� REPAIR/ADDITION(Prey. Sanitation Permit# ..-...._________________ Date .................................. + SepticTank (Specify Requirements) _..........•..............•----.......•---•............-----......-----•--•---..................._........._....,..........--................ Disposal Field (Specify Requirements) •------••----•-••-------•--- ...................•.... --------------------------- ---------- ------------- --•--- -------• --•--•---•----•-----..._...........------•-•........._............-•-...._............................. --------- ---------- -------•--- --- •-•--- -------------••----•----------. ._..........----•--•--._........---............._........... (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done M accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Hent* Owner or licon- sed agents signature certifles the following: "I certify that in the performance of the work for which this permit Is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed .-----•---•................... Owner By `% - IV (if other than owner) FOR DCPA c E�TU �EO LY APPLICATION ACCEPTED BY ... DATE .. .. . . .. ... ..... .. 5 BUILDING PERMIT ISSUED ...-.p,,. . . ..DATE ADDITIONAL COMMENTS .-..-.-. ...................................... ---------------------- --------........-------.,-..............................._... .---.............. ------- .................. ........... _. •------ - r�� Final Inspection by: ............ ...... ..... Date - �-` EH 13 24 1-68 Hev. 5M ................. E ... N JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M