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FOR OFFICE USE: ............. I ........ ........... li APPLICATION FOR SANITATION PERMIT (Cornplets In Triplicate) This Permit Expires I Year From tM#e Issued Permit No/�?-.,Of 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 mods in compliance with County Ordinance Na. 549 and existing Rules and Regvlcrtions.- 16 r , ?�� CENSUS TRACT ....................._». JOB ADDRESS/LOCAT ........ ....... ......... .......... Owner's Nome .......... ..... .,..-.Phone ............. Address 4_ �... — - ------- City ......... ......... .. Contractor's Nome ... .License one ... . .............w......_ ................... Installation will serve. -Residence :trn t House,0, Commercial C]Troller Court 71 Motel Other ...... Number of living units... .. -.1....- plumber of bedrooms Grinder tot Si" .......w._._._..•__._..----..-..--. - Water Supply. Public System and name .......... ............ ........Private Character of soil to a depth of 3 feet: Sand Silt F1 Clay r7 Pect 0 Sandy Loom Loom Hardpan M AdobeC] Fill M6teriol yes, type ....... ...... JPIbt plan, showing size of lot_ location of system in relation to wells, buildings, etc must be ploced on reverse side.) NEW INSTALLATION-pptic. tank ,orsea page,plt.permitted if publit'sewer is available within 200 feet,) PACKAGE TREATMENT f SEPTIC TANK f Size__ .... ...I.... ....... . Liquid Depth .......... Capacity ................... Type Moterial_.. ... No. Compartments ------ - - Distanceto nearest: Well ...... ....... ...............:.foundation ..... Prop. Line LEACHING LINE r] ; No. of Lines Length of each lines--------------- Total Leri6+ - 'D' Box Type Filter Material ......... -...,.Depth Filter Material -- ----- Distance:to nearest-. Well Foundation Property Line. ................ SEEPAGE PIT Depth ..� ................ Diameter ... Number Rock Filled,. Yes C] No Q Water Taible Depth Size ._..-_-w.•.... Distance to nearest: Well, -________________________w___ -Foundation ...... . ..... . .... Prop. Line t REPAIR/A0011TION (Prev. Son itatio.n._ Permit#, � . ._.._....__-......w .. Date . . ........ Septic Tank !Specify Requirements).._-'- .......... .......-_--- .................w_.__....... . ..... ... .... . Disposal Field Specify Reqs cements) .... A:�� .... .. .... .. .... ......... .. li e_ ---- 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 accordama,Qth Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the, San Joaquin Local Health District.'Hem* owner or Hcen- sad agents signature certifies the followingt. "I certify that In the performances of the work for which this permi# is issued, I shall nol employ any person in such stsesrates as to become subject to Workrnon`:rnpensationCalifornia." % t A, Signed...... ----- ---- By ... 4- ................... ........ ....... ..... ��6 Iff other than owner) FOR DEPARTMENT USE ONLY av 1711 APPLICATION ACCEPTED BY -------- - .w_____ ----- ------ ...... DATE BUILDING PERMIT . ISSUED ____1 ................. ___ ......... ........ ... DATE ... . . ..... ------- ADDITIONAL COMMENTS ....... .............. . ...... ......... ----- - ---- - ................. ...... . ....... ...... ...... ...... ...... .... .... ......................... ................... ........ . ........ ... Final Inspection by:..{ �µ-••�- ........ ...... ...... ------- ......... ....... Date ...... . SAN JOAQUIN LOCAL HEALTH DISTRICT E, H, 9 1 -'68 Rev. 5M. N, 9 m