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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT 7 y c/o (Complete in Triplicate) Per No. . .. /............: This Permit Expiros 1 Year From Date Issued Dote Issued .. �3...!..... 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 Countty�Ordinance No. 549 and existing Rules and Regulations: !OB ADDRESS/LOCATION ... 128-Y.7 E• ..TDKft.Y... -4N.Y.. .le*5 . . ... . ..CENSUS TRACT ...... _... ...... ..... Owner's Name ...... . . ..............Phone ....... ... Address . . fl....I�J.!a.. . '.!"es��a....�k'........................................City ....!'Ufa`lu.w«.............................................. Contractor's Nome .. ... :.. .....P.. .�Rf,�.!F_ ... 0 � ��!�.............License #ZsWN...... Phone ..�i�G6:.�b.��...... Installation will serve. Residence 4Aportment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other ..... .... ................................. Number of living units,.. I ..... Number of bedreoms .c;7......Garbage Grinder ............ Lot Size Cly �'�'A ......... Water Supply: Public System and nome ..... ..r............................................ .......Private Character of soil to a depth or 3 feet: Sond❑ Silt❑ Cloy Peat❑ Sandy Loom ❑ Clay loam ❑ Hurdpan ❑ Adobe K Fill Material ............ If yes, type......... .......... (Plot plan, showing size -if 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 j ; Size................................................ Liquid Depth .......................... Capacity Type .................... Material..... ................ No. Compartments ...................... Distance to nearest: Well ....................................Foundation ...................... Prop, line ...................... LEACHING LINE ( j No. of lines . ... .... Length of each line ..... ................... Total length ............................ 'D' Box . . . . Type filter Material ...................Depth Filter Material ...................... ..................... Distance to nearest: Well ........................ Foundation .... .-- ............. Froperty Line ........................ SEEPAGE PIT ( J Depth Diameter ................ Number ..... . ................. Rock Filled Yes ❑ No Q WaterTable Depth ................................................Rock Size ................................ Distance to nearest: Well ........................................Foundation .................... Prop. Lin* ..................._. REPAIR/ADDITION rev. Sonitotion Permit# ............................................ Date .................................) 1 p :c Tank (Specify Requirements) .. . . .. ............................................................................................_...... ......_................. Disposal Field (Specify Requirements) ......... ...... }P1 .��1............ .. ...,p.......... ............ ................................................ 33 .X .2s....... rou„�,.. I...!'f'................................................................. ......... ....I_.......... ...... .................................. ..................................... (Drove existing and required addition on roverst, side) 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with Snn Joaquin Count- Ordinances, State laws, and Rules and Regulations of the San Joaquin local Health District. Home owner or liven- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 �orul not employ any pe non in such manner as to become subiect to W kmon's Com` insation laws of Coliforn:a." Signed � � _. _ ... . ................ Owner �J� By (�L-� Title . /VS. V,.. .. ......... (;f other than owner) V FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ... �.�: ............. .. .............. DATE 1................... . .... . ............................ BUILDING PERMIT ISSUED ...........I........... ..............DATE ... ............................... ADDITIONAL COMMENTS ,. .. 1... .... ............._:....� ...... . _................. .. ..... .................................. ........ _ _. . .r. .... ......... .'... ... ........ . ........ ... ........................... ........... . ...... ... .. ..... .................. ................. .................................... ......I....... _ _ _....... ............................... ......................................... .... Final Inspection by: _ . .. _ _ _........_..._.. ........ ..Date . SAr4 JOAQUIN LOCAs rALTH DISTRICT 7/723 4 ,3 24 1.'68 Rev. 5M