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'MR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No, .......... . This Permit Expires f Year From Date Issued Date Issued Application is hereby made to the Son Joaquin Local Health District for a permit to described. This application is made in comp)#ante with County Ordinance No. 549 and existing install t Regulations: JOB ADDRESS/LOCATION E Owner's Name y CENTS TRACT .......................... Address i/ .............,..:. moi. ......- one .................................. .. ------------ -4 _.--- City - Contractor' :.. .....- s Name Af� . t__:.. .License */, 3cGY..-. Phone .-..- Installation will serve; ......-•----..... Residence[Apartment House 0 Commercial ❑Trailer Court ❑ Motel ❑Other . .............................. Number of living units: Number of bedrooms .--�3_-__.Garbage Grinder .......... . Lot Size .... `.... - .- ,Vcter Supply: Public System and name . - -..--• . "----' • • - Private arocter of soil to a depth of 3 feet: Sand❑ Sift❑ Clay ❑ Peat❑ Sandy Loam Gay Loam ❑ Hardpan ❑ Adobe ❑ 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.) NEVA gw wW1�ION: (No septic tank or seepage pit permitted if public sewer is available within 204 feet,) PACKAGE TREATMENT ( ] SEPTIC TAMC 1 I Size:....................... ... ......... ... .... Liquid Depth Capacity Type ...... .......... Material......:. - . No-. Com Distance to nearest: Well _..... .. ......Foundation - -.-..... ....... Prop. Line ................ LEA043 LINE [ ] Na. of Lines Length of each line ... .. Total Length D' Box Type Filter Material ----................Depth Filter Material ... ................................... Distance to nearest: Well -- Foundation Property Line SEEPAGE T ( 1 Depth P Diameter ................ Number• . . .. ......-. Rock Filled Yes ❑ Na Water Table Depth .. -_-...•- .....Rock Size Distance to nearest: Well ... .. .................................Foundation ...--.... .... Prop. Line RIEifANVADDITION(Prev. Sanitation Permit hP ........ .. DcM ) ...._.--•---•••-•----••---__..... Septic Tank (Specify Requirements) ...... ................ .......... Disposal Field Specify R uirements) ..... 1..rYc--.�GG4,.G._,�, ............... - ...-... ............... .. .... .......-.................... (Drdw existing and required addition on reverse side) hereby certify that I haw prepared this appiisaHon and that the work will be dons in accordance with San Joaquin =aunty Ordinances. State taws, and ltules and R{egirlaRion$ of the San Joaquin Local Health District. Home owner or licea- sod o9ernt;signatum cortiPies the following: "1 certify that in the performance of the work for which IMS permit is issued, I shall not employ any person in such manner as to become subject to Workman's.Compensation laws of Canfernia." Signedner By . ��.- —4, f �-- -{, a T#tee 'ti .. (if other than owner) `-s:- EPARTMENT USE ONLY •--:Y-4■Ri.-._ .-ic1- :.._ -. ._._.-s _.-1-• __. APPLICATION ACCEPTED BY DATE �� .~' G^ ........ .. BUILDING PERMIT ISSUED DATE -------- ADDITIONAL COMMENTS ................... ................. Final Inspection by: ....._.Date .. .n.... ................ SAN JOAQUIN LOCAL HEALTH L?ISTRI i