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FOR OFFICE LJSE:w� APPLICATION FOR SANITATION PERMIT .......................... ........ Permit No. ............ (Complete in Triplicate) .................................... ......... ed .......................................... This Permit Expires I Year From Date Issued ...... Application is hereby made to the Son Joaquin Local' Health District fora permit to construct and install the work herein described. This application is made in compliance with. County--Ord i nb�C'e No.,549 and existing Rules and Regulations., JOB ADDRESS/LOCATION TRACT .... .................. ...... .............................................CENSUS Owner's Name ......... .l._..._. ........................... -•----........................Phone .................................... Address ......11-7-1 -------------•..._------.... jZ1' city ------ . ......... .......................... Contractor's Name ..... ... . .......... ......_.-—. ,Aicense Phone ... Installation will serve. Residence E]Apartment House 0 Commercdal;C3Tro'ller Court- 0 Motel E] Other ..............*......*.......... ------- Number of living units:...___ -.- Number of bedrooms ........:..Garbage Grinder WA.... Lot Size ............................................ Water Supply: Public System and name ................... ........................................7 .......... ........I------•---------------Private v Character of soil to a depth of 3 feet.- Sand Silt E] Clay C] Pea t 0 Sandy Loam.. Clay Loam ❑ Hardpan E3 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.) NEW INSTALLATION: (No{septic tank or seepage pit perned if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ].�'SEPTICJANK t-y ......... ......... Liquid .Depth , .. ...................... Capacity ------- Type Material.&0171_5�,�_ No. Compartments _:7 ................ D' D' ta'nce to:nearest.- Well ....... ................Foundation 10!2.9.............. Prop. Line b�r........... LEACHING LINE (+-�No. 0�f;Lines. __Z--------------- Length'oteach line.%:e,0............ Total Length wlP.................. 6 V BdX1,..o-1ke .. Type Filter Material"_,14&,�..Depth Filter Material ............................•... Distance to nearest- Well ............. Foundation Property Line ......... I owl SEEPAGE PIT Depth Ar:�--- --- Diameter Number ...................... Rock Filled Yes, No C] 4V Water Table Depth ......9510.............................f.7Rock Size .................. I w ........................Foundation Distance to nearest: Wel ... --V:971__ 'Prop. Line ........... REPAIR/ADDITION(Prev. Sanitation Permit# ..........................:...:.....•--..__. Dot ............. ..................) Septic Tank (Specify Requirements) ------------ ------................ ................................... ..--••---------------------------•------•---... ---------- -------------------.........11------------- Disposal Field (Specify Requirements) ........ .................................................. ..............................I------------ ----- - ...................................•........ ---------------------------------------------------.........--------- .......................0.................................................. (Draw existing and required addition on reverse side) Y I hereby certify that I have prepaied this application and that the work will be done in accordance with Son Joaquin County Ordinances, State Laws, arid Rules and Regulations of the San Joaquin Local Health'.66trict. Home owner or [icon- sed agents signature certifies the following: "I certify that in the performance of the work for which this perimilt is issued, I shall not employ any_person in such manner as to become subject to Workman's Compensation laws of California." Signed ............ -- i ...-- ...................... O wn er By .. ..yitle . .l ................ ............. ......... _--- {I ter than owner FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . . . . ......................................•---••-------•-.................. DATE ............... BUILDING PERMIT ISSUED ...... ................................ .......I.............•-- ....... ............. DATE .......... ADDITIONAL COMMENTS ................. .................................................L........ ................................... ------..................................................... .................................. ......................................... -------------------------------- ................ .................................... .................... ------------------ ............................... ....... ........ ................................................ ............................... --- . .. Final Inspection by.. . . ..... . . . ...........................................................................I.............Date ... ..... SAN JOAQUIN LOCAL HEALTH DISTRICT Alt,- E. H.1-3 241.'6B Rev- 5M 71793 9