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FOR OFFICE USE: ��` APPLICATION FOR SAINITATION PERMIT - ..... ........ . (Complete In Triplicate) Permit Na � Date Issued ................................................... This Permit Expires t Year From 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 County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ..... .... _........ ....................... . ............._.. .. .. . ... ................ ..-..CENSUS TRACCTq......... ................ Owner's Name r.....1. .1 .. � �� Phone�EC7/..� Address J pZO6._.S. /.t � As' ._. .....................City ;W,, iaY3 '....... /w Contractor's Nome ��,�.. ..`e— ....License tPWOPI Phone "j- Installation will serve: Residence Apartment House❑ Commercial❑Trailer Court MotelQ Other............................................ Number of living units:...j...... Number of bedrooms ......Garbage Grinder ............ Lot Size A0*-*r/,eAAC................... Water Supply: Public System and name ...............................................................................................................Private [ Character of soil to a depth of 3 feet: Sand j�f Silt❑ Clay ❑ Peat❑ Sandy Loom O Clay loam ❑ Hardpan❑ Adobe ❑ Fill Material ............ If yes,type............... ............ (Plot pion, 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 240 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK f j Size...... .................. ............I........ Liquid Depth .......................... Capacity -------------------- Type ---•-- ------------- aterial•--- •---....---•••... No. Compartments ...................... Distance to nearest: Well .................. ................ oundation ...................... Prop. Line ...................... LEACHING LiNE [ j No. of Lines ........................ Length f each 1 e .......................... Total Length ............................ 'D' Box ..... .... Type Filter Mater 1 ............ .......Depth Filter Material ............................................ V Distance to nearest; Well .......... ............. F undation . Property Line ........................ SEEPAGE PIT [ j Depth ---------—........ Diameter Number ............................ Rock Filled Yes ❑ No07 WaterTable Depth ............. .................................. Size ................................ Distance to nearest: Well .. ................Foundation Prop. Line 7 REPAIR/ADDITION(Prev. Sanitation Permit# ................. -------------------------- Date ..................................) 0 Septic lank (Specify Requirements) ...:... -----------------------•-----.. ...................-, .. . Disp sal Field (Specify Req irements) .. . ..../ .................. - �5 / t✓ .......... ----------------------------------------------------•-- .................................... (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that 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. Hem* owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall not employ any person In such manner as to become subject to Work n's mpensation Ia s of California." Signed - ` -•--• Owner BY - - ---- ------ --------------------- Title ....------- - (If other than owner) FOR DEPART NT USE ONLY DEP APPLICATION ACCEPTED BY _ . _ --. _--------- ------ ---•------- ----•-- - - - .. ...._...... . _ .... . .. DATE 1' ..y 7 BUILDING PERMIT ISSUED .. . --. ... ._...... ....... ADDITIONAL COMMENTS - . ... . ................................... - .._.._...... .._...._..-- -------- ------ ----- ................................ e/p Final inspection by .. ....................Date .. ''.�' ../..._......,...... Fri 13 2a 1-68 1�v• 5m SAN JOAQ IN LOCAL HEALTH DISTRICT 8/7h 3M