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i FOR OFFICE USE. i APPLICATION FOR SANITATION PERMIT '/ p tCempiete in Triplicate) Permit No. fhis Permit Expires 1 Year From Date Issued Date Issued 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCIA yy , , , . / t � � CENSUS TRACT Owner's Nome ._ ....... ... ... Phone . Address / mow _ - 1 . . .. .... City �f l Contractor's Nam ��ly x ._ �.- /iv,r _ . License ilE l� -,,� y. Phone ......... .................... Installation will serve: Residence E�Apar'ment House❑ Commercial ❑Trailer Court C] / Motel ❑Other Number of living units: 1 Number of bedrooms f....Garbage Grinder Lot Size .. ............................. Water Supply: Public System and name .... ..............Private Character of soil to a depth of 3 feet: Sand j] ,Silt Clay ❑ Peat❑ Sandy Loam [] Clay Loam ❑ Hardpan d 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.) C^ NEW INSTALLATION: (No septic tank or seepoge pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ( 1 SEPTiC:TANK(7 Size ` �...� % _ Liquid Depth - V................... Capacity -'Type(A—L-— Material ��' — ,40. Compartments ..�............ Distance to nearest. Well e7e, .Foundation /^ Prop. Line . -�>.../.......... LEACHING LINE [yJ No. of Lines Length of each line / 'I ' Total Length . j �... ............ 'D' Box Type Filter Material - -Depth Filter Material - . ../..`y........................ . S Distance to nearest: Well ��'.. . . Foundation /[' Property line . .... ................. i 7 1 SEEPAGE PIT (r( Depth s Diameter Nvmbe• % Rock Filled Yes No Water Toble Depth Rock Size Distance to nearest: Well A1.41) _ _. ....Foundation /n Prop. Line ..�................ REPAIR/ADDITION(Prev. Sanitation Permit* Date _ ) Septic Tank (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 in accordance with San 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: "1 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." i Signed Owner'^ By L =r l 11FG-L`I.: Title ful'I..Le��4 (If other than owner) �r FOR DEPARTMENT USE ONLY _ APPLICATION ACCEPTED BY v DATE � /of BUILDING PERMIT ISSUED DATE _ ADDITIONAL COMMENTS /-7P'�G� Final Inspection by. `•f Date SAN JOAQUIN LOCAL HEALTH DISTRICT r /1 i W,J E. H. 13 24 1-'b8 Rev. 5M 7/72 3 11