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FOR OFFICE USE: ....... ..., ...................................... APPUCATION I FOR SANITATION PERMIT (Complete in Triplicate) Permit No.. ... .......... ........ This Permit Expires I Year From Date Issued 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 Na. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION....0-?fir. .... .............................................._CENSUS TRACT . .......... __ ........... Owner's Nome................................I......... ..........Phone...,............................... Address ...... ............. city Contractor's Nome. License# Phone .................... installation will serve: Residence ipartment Housed Commercial OTrailer Court a Motel0 Other ............................................ Number of living Number of bedrooms .._3 .. Garbage Grinder ............ Lot Skre — - — — — - — -_-_-------------------- Water Supply: Public System and name .. ...... ...... ........... -------- Character of soil to a depth of 3 feet: Sand 0 Silt C3 Cloy rj Peat [3 Sandy Loom 0 Cloy Loom [3 Hardpan 0 Adobej� 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.) PACKAGE TREATMENT j SEPTICTANKI) Sixe ............... ................................ Liquid Depth ...:-.._.w...,............ Capacity ................... Type ......... Material....................... 140. Compartments .......... Distance to nearest: Well ....................................Foundation ........ ............. Prop, Line ....... LEACHING LINE No. of Lines .................. Length of each line.........__................. Total Length 'D' Box Type Filter Material .... ..................Depth . Filter Material ... ......... Distance to nearest- Well ......... — foundation ...... Property Line ........ ..... . ....... • SEEPAGE PIT Depth ... ...... . Diameter ................ Number __ .................. Rock Filled Yes No Water Table Depth ... ......... .... ........_.............Rock Size ..........................._,_-- Distance .......... .........Distance to nearest. Well ........................................Foundation ..................... Prop. Line .. ...... — ......... REPAIR/ADDITION (Prev. Sanitation Permit# ......... _ ................................ Date ................... . .. . ....... Septic Tank (Specify Requirements).................. ........ ...... . . ...... ......... ............. ...... ----------- . ........ ......... ...... Disposal Field (Specify Requirements) ................................. ....... .................. ............ .............. ....................... . ............. ..... .... ...... , l-' . ....... .............. (Draw existing ande required addition on reverse side) I hereby certify that 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. Horns awrler or Been - sed agents signature, certifies the following - "I certify that in the performance of the work for which this pormit is issued, I shall not employ any pilir"M in such manner as to become subject to Workman's Compensation " laws of California." Signed .... ......... _ ........... ..... Owner 4 4 TitleBy ........... (if other than owner) FOR DEPARTMENT USE ONLY 7— APPLICATION ACCEPTED By'.. . ......................... ............................ DATE ... ------------- BUILDING PERMIT ISSUED.... .................. . ............... * - ,....... ........ ........ ............. ADDITIONALCOMMENTS .................................... 7— ............ ... . ....... ......... ............................ ...... .......................... . .......................... . ... . .............. ......... . ... . ... ...... _ ......... ....... _ ......... ...... . ................. ................ . ................ .............................. ................................................ Z-'- -------- ---------------------...... .... .............. ...................... . ....... FinalInspection by:...... ................... . ................................................ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.13 24 1-'68 Rev. §M__ 7172 3 m