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FOR OFFICE USE: .......................................................... APPLICATION .FOR SANITATION PERMIT Permit No. .......... (Complete In Triplicate) Doti Issued ...'/ -36 ,76 .............. .. ...... This Permit Expires I Year From 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/LOCATION 1. V...JeW.......1;�;1.(-_!4..,CENSUS TRACT .................... Owner's Name --- 4 6P--*-I�.o - �,6, -) --- ..............................................Phone Address —------ ey- ............. .... ........ Sc off/ ......... .......111-1........... ---------- j...................... ..........City ... Contractor's Name ---------- ----------- •--•-•••--... ...............License # .........I...... ........ Phone ... ....... Installation will serve: Residence RApartment House 0 Commercial oTroller Court 0 Motel []Other ....................................... Number of living units:...1------ Number of bedrooms _-...._Garbage Grinder Lot Size .... Water Supply. Public System and name ............................. ............................................................................Private Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay 0 Peat 0 Sandy Loom 0, Clay Loom 0 Hardpan r] Adobe 0 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 permitted If public sewer Is available within 200 feet,) PACKAGE TREATMENT f I SEPTIC TANK Size...................................I............ Liquid Depth ................ ...... CapacityType Material._41vyr,.keJ Np. Compartments _9=_............ Distance. to nearest. Well ---------s. ................Foundation ... ., -............ Prop. Line ....... ............. LEACHING LINE No. of Lin .................. 4 LinesLength of each line........ J'49............. Total Length .....? ......... 00 'D' Box ............ Type Filter Material ....................Depth filter Material ........... ................................ Distance to nearest: Well .................... Foundation ................... Property Line .................... Depth ------- eter ---41..Diam SEEPAGE PIT _ . Number ----- ........_._.._Rock Rock Filled Yes No Water Table Depth ...............................Rock Size ....... ......... Distance to nearest: Well ............. ......___.._--------....:Foundation Foundation ....4-0........ Prop. Line ............I REPAIR/ADDITION(Prev. Sanitation Permit .................... ................ Date ................................ Septic Tank (Specify Requirements} .................._................I.......................................... ............. ........... Disposal Field (Specify Requirements) ............................................. ........_......... ............ -------------------------------- ------- ----- ................---------------------------------4........I----------------I——------------------- ------- ...................-1........... ...................... ......................... . ------------------------------------------------------------------------------------------------------------...................... .................................. ............................. (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 Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health,District. Home owner or licen- sed agents signature certifies the following: "I certify that In the performance of the work for which this permit is Issued, I shall not employ an person In such manner as to become blect to Workman's pensation laws of California." Signed ------ Owner ... By ......... ------------------- . ........... ------ ---------- _------:--------------------- Title _._----- .... ........................... (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _...... ---- --- -- . ......... ----------------------------. DATE ... ............... BUILDING PERMIT ISSUED ...... ...... •.....-•- .-........ ..-DATE _.................................... ADDITIONAL COMMENTS .... ------------ ------------_- ............. ------------------ ------------------------------------- ---------------- ------------ --------1�....... --------------- ------------------------------------------------------- -------------------- ------------- ----------- -- ------- ........................................................ -------------------------- --•---•---=-•--•--- ----- ------ --- ............... .. .... - ----- ------------ ....................... Final Inspection by; ....................... . -- -- ------ - -------- ---------------- --------------------- .....Date -41 t �.e ............... EH 13 24 1-68 Rev. 5H AN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M