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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. --4 .».......... i #. .�... .-- (Complete in Triplicate[ �/!. Date Issued. Z�-7] This Permit Expires 1 Year From Date Issued Appli� cation is hereby mode io the Son Joaquin Local Health District for o permit to construct and inssall the work herein described. This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: ..L�1CiB ADDRESS/ TIO CENSUS TRACT. .....•._.•__.-..-.-....----- N..- �� _. f s . �+•as,s.d c C Gs t. Phone ....... ................ ....... Owner's Name .......... fs•a.d. _ ... icy Zip --_...._.. Address r .-._.. ... . .......... Contractor's Name Installation will serve: Residence [ Apartment House❑ Commercial ❑ TTailer Court ❑ Motel ❑ other_.._..................... ............... Number of living units:. . --I........Numkier of bedrooms ._.....Garbage Grirtder............Wf Size... ..... .. ...,_............................... Private Water supply; Public System and name........ ..©-- . .....� ........ .�. ..... �.. -• • ---•- Character of soil to a depth of 3 feet; Sond llt _Cloy. Peat Sandy Loom D Clay Loam 0 Hardpan ❑ Adobe Uf Fill Material if yes, type---••-••---......... . • IPlot plan, showing sire of lot, location of system in relation to wells, buildings,etc. must be placed on reverse side.} NEW INSTALLAT110W INo septic tank or a$e pit permitted if public sewer is available within 200 feet,} f _ 5kxe-� - Liquid Depth . PACKAGE TREATMENT I 1 SEPTIC TANK . Capacity �� a c?.... Type Material.. I.4.-R', r- No. GQmparfinents.. . .�-....._... .... yr.._... Prop. Line ._ .._... n Faundatiian ..�' e Distance to nearest: Wall... l o.a. ..........Length of each line .. r'I�r Total Length....__-�` .. ... �• LEACHING LINE I � No. of lines . .. '- 'D' Box. Type Filter Material, .- -S fZ Depth Filter Material. .- - :......r•-•••••-......................... Prop y Line...... rr`. - ... Distorm&to nearest:Weil - ...+ Foundation......._f.P. __ SEEPAGE PIT ( Depth_,,2;:;r�l-iamel'lfl'. ...4 •� _.Number_....... .................... I ,r Rock Filled Yes No❑ Water Table ........... .I............_... Rode Distance to nearest: Woll........ .1.1..fl.�.t" Prop. Lin .---...... Founda!>im..».. �. -•.-.. e-. Fc..... , ev- Sanitation Permit tit................._. ... .. »....--._. .......--.ppte....__-------. REp/siR iADD1TFQN (Pr . ...__......_.....__ . .� Septic Tank [Specify Requirements) .............................»...._.............................,............... pisposal-Field [Specify Requirementsl._.�_.....-----�..._............... ....__..... ,........ ».._......._.�............................... ....................... .................................................._...... . [Draw existing and required addition on reverse side} I hereby certify that I hove prepared this application and that the work will be done In accordance with son Joaquin County Ordinances, State Laws, and Rut*% and Regulations of the Son Joaquin Local Health District. Horne owner Or licensed agents signature coctifies the following: ` "I certify that in the performance of the work for which this permit is issued. l shall not employ any person in suc#s 'manner as to become subleet to Workman's Compensation Iorws of California." Signed ...... ........................._.. .. .....-. . ,� OwneK B ....... ......_........................_.. s `r- :.... y- ... i;lf other than owner) FOR DFIRARTiI ENT US! ONLY APPLICATION ACCEPTED BY.......... .. ....•.......__. DIVISION F LAND DUMBER ............... .....__...DATE......... ... ADDITIONAL COMMENTS ....... _,.».,..»..»... ..__.....ri.............. ._�. ... ...».............. ......_`.._:........._. ... ............................. .. ...�._...._ dace. ......... . Rnal Intl on byr.........Z... .... . .... . .. .... FiS 2167] tstV.7I76 am IN 12 24 SAN JOAOUIN LOCAL HEALTH DISTRICT