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FOR OFFICE USE; APPUCATUON FOR SANITATION PERMIT # (Com;.leto in Triplicate) Permit No. is .. .... - This e Permit Expims I veor From DotIssued Date Issued .&/`..).r?7.73 Application is hereby mode ,o the Son Joaquin Local Health District for o permit to -onstruct and install the work herein described. This application is made in compliance with County Ordinance No. 549 ono axis+:ng Rules and Regulations: JOBADDRESS/LOCATIO .... . .. . . '�? x: fV9 _ vi✓��.G'..�.. ..`�ICiP�J�:��v7.�r. /E'/.7 CENSUS TRACT ....... Owner's Name.W...t ......._.. ..................................................................................Phoneli `lt.. Address . .. ..c�.3 a�u/.. ....��.s��:/�._S!�5:�('�!/k1E<V..T�r.RiCir , y ... �...,Q.�... ........... Contractor's Name . /.. f _..... ...........f:�h+r� .. .�._. ....License # .c F e-2 Installation will serve, ••••-•••-••••••--• Residence IAApartment House Commercial ❑Traller Court i] Motel❑Cthm .................. k Number of living units:.. ......... Number of bedrooms ............Garbage Grindar ..... .... . Lot Size Water Su I , Public �..... S.,IC S` ......... 1 ' PP Y System and name ... ...... ...... ... ......... .......... . . ....Private kCharacter of soil to a depth of 3 feet. SandSi!r❑ Cloy ❑ Peat❑ Sandy loam ❑ Clay loam Hardpan O 'dobe ❑ Fill Material .. .... If yes,Y typo L- (Plot Plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) o septic tank or seepage pi: permitted if pu4 NEW INSTALLATION: (No sewer is available within 200 feet,) PACKAGE TREATMENT ( ] SEPTIC TANK j ] Size......................... Liquid Depth ................... Capaaty .. .... ... .... Type .... ............... Material...................... No. Compartments k Jistonce to reorest: Well Foundation ...................... Prop, line ..........._.... ............................... LEACHING LINE ( ] No. of linos •"- I - - - ...- Length of each line Total length Box . ...... .. Type Filter Material _..................Depth Filter Material ..... ........... ........................... istonce to nearest: Well ........................ Foundation ..... ...... ........... Propoey Line SEEPAGE PIT ........................ O Depth _............ Diameter Number . ........... .......... ... Rock Filled Yes ❑ No Q Water Table Depth ................................................Rock Size ................................ Distance to nearest: Well ........................... Foundation .......... ............ ....... Prop. Line ............... REPAIR/ADDITION(Prov. Sanitation Permit# ...... . . ............. -..-........--•--... Date ................... Septic Tank (Specify Requirements) ...... .............. Disposal FieldS ( pacify Requirements) ....... .'..f../..T.�,..... �. `. '` �—Sl.. N!iG=.... va......... ��.... . . ............... ... _.......... ..... .............................. .............de ........... . . . row existing and required addition on reverse side)...... . .... ........................I........ 1 hereby certify that 1 have prepared this application and that the work will be done In accordance with Son Joaquin County Ordinances, $tote lows, and Rules and Regulations of the Son Joaquin Local Health District. Horne owner o, Ikon. ued agents signature certifies the following: "1 tertify that in .he performance of the work for which this permit is issued, 1 shall not employ any person in such manna as to become sub),tot* Workman's Compensation laws of California." Signed !1 .� ��FG . ...... .... . ............... Owner Bytitle . .. ... .. . . ... . (If other than owner) FORDEPARTMENT USE ONLY APPL+CATION ACCEPTED BY+W [� J- ..... . ................................ CATE ..... ....� BUILDING PERMIT ISSUED .......... ..... ADDITIONAL COMMENTS "" DATE ....... . ................. .......................................................................................... . .............. ......................................... ...... . ......................... . ilnoi +ns ecr on b ........... . ...... .............................. ..... ............. ... .................... . . Date - SAN JOAQUIN LOCAL HEALTH DISTRICT E H 13 24 1-'c8 Rev. 5M 7/72 3 m