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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ........... .......................................... Permit No. ..7.�.. -s (Complete In Triplicate( ..�... ar This Permit Expires I YeFrom Date Issued Date!:sued Appikctlon 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 ADDRESS/LOCATION .............. TRACT ............ Owner's Name ..X1..G.I....... ........ -.................. ... ..........•. ..�" ..Ph0ne Address ....._.AZ.�.... ......... . -4.c_ .t�::.1._.....................City . �,=`�2: ............ . ..V.0.................... Contractor's Name # 1/.. ... Phone �J. . installation will serve:: Residence[ Apartment House C3 Commercial[ 1'rallerawo ther Number of living units:...!._.... Number Motel[3Dome..c . ..Garbargs Grinder• :. Lot Site ......�. .- =�`.-...... Water Supply: Public System and name . ..................................................Private❑ Character of soil to a depth of 3 feet: Sand D Silt Q Clay Q Peat Q Sandy Loom C3 day Loam❑ HordpanW Adobe 13 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 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT ( ] SEPTIC TANK A Size. Liquid . :(`.:J.,X/.. /............ cid Depth ..�.................... CapacityA.G.t-a-& Type :�:G Matwlal. �:r. �: No. Compartments ....�.:............ Distance to nearest: Well .....h=..../...................Fou``ndaation ..ZC. ........ Prop. Line .........._..... LEACHING LINE No. of tines ..... 7............. Length of oach line... . ............ Total Length c ..�......... 'D' Box ...1...... Type Filter MaterialX,',�rCt....Depth Filter Material ..l��f.............................. 410 Distance to nearest: Well .. .................. Foundation .1��... ........ Property Line ...�. .............. a SEEPAGE PIT ` Depth .......... Diameter ��.`.... Number ......�................. Rock Filled Yes No [] Water Table Depth -. ....Z...................................Rock Slice ... .. ........... f Distance to nearest:Well ,�i ........................Foundation ... d........ Prop. Lina ... ................ REPAIR/ADDITION(Prov. Sanitation Permit# ............................................ Date ................................ .I SepticTank jSpedfy Requirements) ................................... .... ..............................»......»...................._....................... .... Disposal f=ield (Specify Requirements) ................................... . ............................ ........................................................... ............................................................................................................_............................................................................................ (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done M accordance whir San Joaquin County Ordinances, Stats Laws, and Rules and Regulations of the San Joaquin Local Health DlsMd.Home owner or !kern sed agents signature certifies the following: "I certify that in the performance of the work for which this permit Is Issued, i shall not employ ante person in such manner as to become subject to Workman's Compensation laws of California." Signed . r.... .. ......... Owner By ._ �. ...................... Title E- : ., � ... .: ��7................... ...... ......... (if other than owner► FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ......... DATE . ." -7.72. .................. BUILDING PERMIT ISSUED ......................... ..I ............................................. ...................... ......DATE . ........................................... ADDITIONAL COMMENTS .......................................................... ............................................................................................................................................. .................................................. ..............._....................................................I..................... Final Inspection by: .0. .. .. ... ........................................................... .................................... .Date 2? / .. ................. .. .. ...... // EH 1 ... 3 211 2-613 H[ay. SAN J OAQUIN LOCAL HEALTH DISTRICT 8/7h 3M