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FOR OFFICE Ur2- APPLICATION FOR SANITATION PERMIT ................................••-.__._._.---•- Permit NO. . ..........I................I................ ...... (Complete in Triplicate) .... ........ " ............................. This Permit Expires I Year from Date Issued Date issued Application is hereby made to the Son Joaquin Local Health District for a permit mit 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/LOCATIPN ........................CEN%IS. TRACT .... -------- Owner's Name -4�/.[Z------ .. .......... .................................!7. .........................PhoneF A fl) .. ......I - - -5 F- ............................. Address �Zo//F/ ., qlle-Al.........----------city -4?zxL--............... . Contractor's Name ........(,r�--- -------------------L........License# --:----------------------- Phone Installation will serve- Residence f3 Apartment House E] Commercial ]Trailer Court 0 Motel []Other....... ..................................... Number of living units...___)----- Number of bedrooms -2-....Gorbage Grinder .......... Lot Size ................................ Water Supply. Public System and name ..................................... -------------__............................ ............. ...Private Character of soil to a depth of 3 feet: Sand Iff Silt 0 Clay 0 Peat 0 Sandy Loom 0 Clay Loam'o Hardpan 0 Adobe E3 Fill M6terIol ............ 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,) ZF PACKAGE TREATMENT SEPTIC TANK; ] Size.--•......... .........................•........ Liquid Depth -------------------- Capacity ---I--------I........ Type ... Mat 101............. ......... No. Compartments .......................�r Distance. to nearest: Well .......................... ........Foun tion ...................... Prop. Line ...... ............ LEACHING LINE No. of Lines ........................ Length of e line--____ ..................... Total Length -------------L.............. 'D' BOX ... ... Type Filter Material .... ... pth Filter Material ......._............._.._...__._._-.........LA. Distance to nearest: Well ........... .... Founds on ........................ Property Line ....•.................. _.,.n Material e Length a f Le th .e -M F c 0 0 h u u Mat t n- d n ________Foun.0-u ch n t D P, Fit on ....... e u um m Filter I r ............ SEEPAGE PIT, Depth --------------------- Diameter ......... Num or ............................ Rock Filled Yes ❑ No 1� Water Table Depth .......................•................ ......Rock size -1............................ Distance to nearest. Well ........ ..............................Foundation .................... Prop. Line .... ................. P REPAIRADDITIONIPrev. Sanitation Permit* ..--•-•_____ ___ ....................... ..... ... ............................... Date ...6......................... Septic Tank (Specify Requirements)-............. ....... ......... .............. ............ ......... ............. W-------------- -------------- . . .... Disposal Field (Specify Requirements) ... . ...... .. ...... r ..............---------------------------------------- .......................... ............. ......-............. -------------...........................I.................. --------------------------------------------------- ---------------- -------------------------------**------------------------------------------------- ............................. IDraw 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 San Joaquin Local Health,,District. Home owner or licen- sed agents signature certifies the following- -J "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 Wp*man's Compens tion laws of California." Signed -------- - ;-- -- --------I--- ----- ------ --•-.....-...----------- Owner -A—--— By —--------- --a ----------.1--------- -------------------------- Sitle .-----.---•----- ------------ ............. ...................4 (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ....../ --------- ---- -- --------- ---- ............ ----------------------------- DATF --------- BUILDINGPERMIT ISSUED -•---------------------•-----------------------------------------------------------------------------------DATE _.................................. ADDITIONALCOMMENTS -...---•------•- ...... --------------------------_.•_--__-___....--- •----------------------------...... ..............................................--- --------------------- ----------------- ------------------I---------------—--------------- -----------*------------------------------------------------------ -------------------- ......... ....................... ---------------- ---------------- ..........6.......................................................................... --------------------------- --------------------=---------------- -------------------4--------------------- ...................... ...... ----------------*.............. ............ Final Inspection by. ... ...... ......................... ........ ------.................... Date ..Oate .. ......... ------- EH 13 2b 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DIS.TRICT 6/7h 3M