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FOR OFFICE USE; �pAPPLICATION FOR SANITAYION PERMIT (Complete in Triplicate) This Permit Expires I Year From Data Issued FOR OF'Fl&-USE: Permit No._.7�_./_?.r Date Issued.., ./y7? -P 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 ADI)RESS/LOCATliDN.-,,.,S.-,.,.,. ..... _CENSUS TRACT Owner's Name ...... __U04. !!�� - ................... . ....... ........ ..Phone... Address. .......... Contractor's Name. A; L- -- .............License Installation will serve.. Residence @g-' Apartment House Q Commercial M Trailer Court MotelEl Other .............................................. Number of living units:...___....,Number of bedroom$, Y. Gorbage Grinder..... ....... Lot Water Supply. Public System and name..,.. ....... _ ...... .................... . ..... ...... ........ I ................ . ....... .... Private Character of soil to a depth of 3 feet. Sand [] Silt 0 Clay rj Peat 0 Sandy Loom @0*' Clay Loom 7 Hardpan 0 Adobe C] Fill 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 SEPTIC TANK Size......__.._._............................................Liquid Depth................._._._.. Capacity .............. .......Type- ... . ............... Material ....... ..... ........ No. Compartments-, - -_ - - .(> Distance to nearest: WelL.....- . ................... . Foundation, . ...... Prop. Una ...< LEACHING LINE No. of Lines................._....._.....Length of each liner ....__..................._....Total Length...._..,........... 'D' Box........,...Type Filter ....... Depth Filter Material.......... Distance to nearest- Well...,......._......_ _...Foundation..........--.....----.....__ Property Line. - SEEPAGE PIT Depth...,..,....,....Diom9ter ........ ........... Number. ......... Rock Filled Yes M No ❑ Water Table Depth_ ................ ................. ................ Rock ............ ------ Distance to nearest.. Well .............. Foundation.. -____--Prop. Une.......... REPAIR/ADDITION (Prev. Sanitation Permit# ................................................-Date........-...... __ ......... .) Septic Tank (Specify Requirements) ................................... -- - ------------ _.». - ----------------------- ------------ Disposal Field (Specify Requirements)...,....a 1A, 4, ... . ..... . ................ . ... . ....................... . .... ...... ............. -------- - - --------- ........... ... ... .... __ ......................... .--. ... (Draw existing and required addition on reverse side) I hereby certify that I have prepared this -application and that the work will b* don* In accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licensed "ants signature certifies the following: "I terrify that in the pe4ormanc& 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 Compensation laws of California." &.....................................Owner Signed... ... ___ ....... n BY ----------- (if other than ownw) FOR DEPARTMENT USE ONLY P9 APPLICATION ACCEPTED BY...._.._ lo;?e.7,Z,..................DATE...- DIVISIONOF LAND ... .... ..... / .. ............................. ........... __ .... DATE............:.............._.__............_._. ADDITIONALCOMMENTS ............................. ..... . ......... ____ -------- -- ------ ----------- ___ --------------..._...__.._.......................I_--------.-.._.--:. *--** ---- - - --- --------- Y..._..... ........ ... . . . ... :, � , ".. � � .... . .. ............... .......... ............. ........... Final .Inspection by: . .... . em 13,24 SAN JOAQUIN 1.0-AtHEALTH DISTRICT FAS 21677 HV, 7/76 3m