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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete In Triplicate) Permit No. ......................................................... ..7 .. ......................................................... This Permit Expires 1 Year From Dote Issued Date Issued S.....S 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 mgdo in compliance with County Ordinance No. 549 and existing Rules and Regulations: J08 ADDRE55/IOCATlO �� a� ------ • -c.4 +' L ! J' .�_y..� CENSUS TRACT &...070- .. Owner's Name ...5 -----. . ---•-• . . fts� �,r si•^7-[f!1.... ......_ Phone ................................._ Q ............ Address ......-...!^�(.....� ....... -/ �f........... .... ........._.City Contractor'sNome ... - ..License# .`&SZ,— Phan ................ Installation will serve: ResidenceApartment Housefl Commerc al ❑Trailer Court ❑ Motel ❑Other ... ...../&x � Number of living units:...------.- Number of bedrooms ---•........Garbage Grinder ------------ Lot Size ............................................ Water Supply: Public System and name .............................._._......................_....._....._......_......__..-_...._.._..._...Private❑ Character of soil to o depth of 3 feet: Sand o Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam❑ Hardpan❑ Adobe ❑ Fill Material ............ If yes,type .......................... ti (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.{ cjI 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 .................... Type .................... Material...................... No. Compartments Distance to neareatt Well ....................................Foundation ................ Prop. Line ...__..._.».__... LEACHING LINE ( ] No. of Lines ........................ Length of each line............................. 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 {] WaterTable Depth ......._..._..................................Rack Size ................................ Distance to nearest: Well ........................................Foundation ..........-..-..... Prop. Line .............. REPAIR/ADDITION(Prov. Sanitation Permit# ...................................._.._.. Date ............................... Septic Tank ISpecify Requirements) ................/.�...,�........ „_ Disposal Field (S ecify R uirem ts) .QFSE[... .... _.t 4r � r 3 ( ....-„�......,,,,, --------�dJ..!.....�- ...---..Q&----...... �P� �� .. . ........._r'�3_�.�-X2� ----------------- ..../......_.......-.............................................------.............................................. ........................................_............................. (Draw existing and required addition on reverse side) I hereby certify that 1 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. Home owner or licen- sed agents signature certifies 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 Work a ' Compensation laws of California:' Signed .............--------- -.... ....... ..... ...... ...... -- .. . . Owner By ........_........... ............... - `^ .. ... 4... 7ttle - /].(.,@ ..�.:.. (If other than wner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _._-----------------------.._........._---.._ DATE .........:75....__............. BUILDINGPERMIT ISSUED ......... •-••..........................:.................................__._._................._......DATE ........................................... ADDITIONALCOMMENTS................................._................._----•.................................................................. :.._.._.__................ ......_._...._..---••......................................................................•----• ..................................................................--........1--................. _.... .._---------------- ----------------- ............. ,_,,,....•-------........_....---------- -- ...................- _ ..... .. _._.._. p .. Flnal lnapection byt ...._.... .. - .. >2 ........ ...... ..............................I......._.... ..Data•."..... .... ............-•- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.13 24 1--68 Rev. SM 7/72314