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rUK UFMCE USE., APPLICATION FOR SANITATION PERMIT .... (Complete In Triplicate) Permit No. . ":SS ..... ........................... ... This Permit Expires 1 Year from Date Issued Date lssued ..T:�4. � 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/LOC ON ��HLr� y Y- 4.. NSUS TRACT ......... ............... Owner's Name ... . ...... .. ....... .............. ............................... ._... Address . . . .lam. _ City....- --FSCs: .....Pho a ..... .. ........... . Phone .W Contractor's Name :.....License # 18 „3Y....._ Phone Installation will serve: Residence❑Apartment HouseCI Commercial{]Troller Court '] Motel ❑Other .--n.... Z1Zr,�a Number of living units:.... Number of bedrooms ....IVGarbage Grinder ............ Lot Size .. .....:mac -- — Water Supply: Public System and name .._...___... -•......................-•-------•---•------------•-•---- .....Private Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat[I Sandy Loam Clay Loam ❑ Hardpan ❑ 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 s€de.) NEW INSTALLATION: (No septic tank or see age pit permitted � public sewer is available within 200 feet,) PACKAGE TREATMENT [ I SEPTIC TANK Size ---- --- --- ,r . .. ...... Liquid Depth ...`` Capacity l p y0�. Type4LMaterial... , ,,.. No. Compartments Distance to nearest: Well _......... Foundation ..__ /� --•-•- - . .. . ....-•---- Prop. Line ....��. ACHING LINE fkflNo. of Linesa Total Length - .......... .........__. Length of each line........... - ��--. .�'...... 'D' Sox /------ Type Filter Material ....y �-•• • _-e'�...Depth Fitter Material _ Distance to nearest: Well ....... :57to,- Foundation ....1a0 ..._ Property ,Line .'�+. .. .. ...... SEEPAGE PIT [1'� Depth .....-2-�� Diameter .........------�...... Rock Filled Yes �No Water Table Depth _...------- - Q ".---- ---Rock Size r Distance to nearest: Well ...... Foundation.._....Foundation --. 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 Joaquln 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: "I 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 LComnsation laws of California." Signed -. ----- • - Owner � BY ----- --- (if offer than owner) r Title _. .. ......... FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYP- ---------------------------------•----------- ------ DATE . ..r .h3 ..7�_..._.._.._....___ BUILDING PERMIT ISSUED -.-- __..- -- ------------------------------ ---DATE ................. ADDITIONAL COMMENTS ------•--------•---------------------------------------------------•-------- .......... ------•----- ......... ---------------- _-- Final Inspection by: _____________ - - EH 13 21a 1-613 P(ev, .. .. _..---•----...Date ..... . ..z3.. .. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3M C�