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FOR OFFICE USE: 'AAPPLICATION FOR SANITATION PERMIT Permit No. :..?- -. (Complete in Triplicate) . ................A-—...-----...----•... -. Date Issued This Permit expires I Year From Data Issued ^Application is hereby made to the San Joo vin Local Health District ror c permit to constrvet and instal( the work herein described. This application is made in tom�liance with County Ordinance No. S49 ono existing Rules and Regulations: :OB ADDRESS;LO}C-�ATION ^ ' ; ................................................... ^...... .CENSUS TR..A..�CTku .......... .....Phone Owner's Nome .....- _ _ - - Address .. �.i?R\ c..................•......_..-. l.... v.,........ _...._ ...City �h„,..._.— ..,.. ontractor's Name _ ...License # ........................ Phone -............... -•------- w lnstollation will serve: Rosidence)!�Apartment Housef-1 Commercial -Troller Court [] t Motel ❑Other ------------------ ----------------------- t Number of living units:_.._ ------ t._.._. Number of bedrooms Garbage Grinder .. Lot Size ..__S_ -s�-.........• ---------- ---- Water Supply: Public System and name ___ Prrvote Character of soil to a depth of 3 feet: Sond Silt❑ Clay Peat L] Sandy Loam ❑ Clay Loom Hardpan _ Adobe ❑ Fill Materia! ............ (f 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 200 feet,) C PACKAGE TREATMENT [ I SEPTIC TANK J Size........--------------- ..-_--------- Liquid Depth -------------------------- Material --------•---------.---- C ^� t�9,._ Type s� --• Materia{__ k,Fe -__. No, Compartments .-- ..r----...----- C Capacity �,��G. � n r Foundation .- Proo. Line ...- Distance to nearest: Well �._:?'�..`��_l}�o----....----• � n k LEAEWING LINE [ 1 No. of Lines .. Length of each line__._--91C .............. Total Length ...... V D Box .... Type Flit I, Mott:riol q,��_.Depth Filter Material -- - K-~------------•----••- J Property Line �'_.__----._. Distance to nearest: Well 1` _�ti► ... Foundation .. _____....-----•-•---- Numbe I Yes No SEEPAGE PIT [ J Depth i , D"►ameter ...-----_-••----....----••- Rock Filled ❑ Wates Tdtiie Deptri - ......Rock Size ------ ------------------------- i V �...... .......---------.�...__....----� .Foundation ----•-------•------- gyp• Line - --••------....---- Distance ronearest: Well --..............................•----• REPAIR/ADDITION(Prov. Sanitation Permit# -...........................,............... Date ............... Septic Tank (Specify Require►nePls) -----------------------------------------------------------------------------•---.._.. Disposal Field (Specify Requirements) ................-------------------- --- ----------------------------------- ------•-- .......... ................ ........................ - . ... •-- --••---- (prow 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 Reguiations of the Son Joaquin Local Sao sed District. Horne owner or lieen- sed agents signature certifies the following: 111 certify that,in the performance of the work for which this permit is Issued, I shall not employ any person in such mannlr as to beco .i subject to Wt-irlman's Campelsation laws of California." ....... Owner Signed... -: � -,._�,---•-- �• ............ . .... .. Title ......... ............................................................. By .. ... ......• ......er)....................... ...................._... other than own , FOR DEPARTMENT USE ONLY r� . .. I• vu-► ...:1j 1- DATE .............. APPLICATION ACCEPTED SY ' .\ , ..-DA^...................................... .. � PERMIT .. ...... �="'-� ........................, -•--- 4 ADDIONAL COMMENTS .. ........... ............... . , .. ....................... ...; ,. ^ . .......... ..ti.....�. ........ 1 • ................. ... ..... .... . ..... \ 4 ..... ... .....•..... ..._.. .',.. i. Final inspection b .... �,,:_1r._�...r =• _.._. .. .. , 5„N JOAGUIN .00A_ I(EALTH DISTRICT e u o i-'AA 2.v. 5M