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rVK VI ITt i15E: . APPLICATION FOR SANITATION PERMIT d� (Complete in Triplicate) Permit No:. .............. ................••--......._. This Permit Expires 1 Year From Date Issued Date Issued ./-..:. 2. � Application is hereby made to the San 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,, JOS ADDRESS/LOCATION•.../J� Jr 36�.( ��_...VQ .............................. .CENSUS TRACT Owner's Name ............. j Address _ ................. f- v.... .... .�. Phone.. '�'.�'`100.7.i... ............................' ..... City ...... - ...................................... Contractor's Name /� �l ... .... ?c g��J.... .:.... license # ......................... Phone Installation will serve: Reside ince partment House Commercial ❑Trailer Court 0 Motel ❑Other Number of tieing nits,..::.._.... Number of bedrooms . Gorba a Grande Water Supply- Public S ...._....a. .��.... .. .... x .�?........ pp Y System-and Hama ............... ................... _ u ��"�. ..Private❑ r Character of soli to a depth of 3 feet: Sand 0 S#lt❑ Clay ❑ pea �] Sandy Loam ❑, Gay Loam Hardpan p Adobe_ .I+tll Material !# yes,type , ...... {Plat plan, showing size of lot, location of system:in relation to wells, buildings, etc, must be placed. on ravers, side.} NEW INSTALLATION:. (No septic tank or'seepage .pit permitted if public sewer is available within 200 feet;} PACKAGE TREATMENT:i I ] , SEPTIC.TANK ,.: } Ma ............... 4 Capacity . ize.:.----•�--•.-•-- . liquid depth .................. :.. Type;. ...__.....;.... terial...................... o. Compartments .............. . Distance to nearest: Wel! .� � •......:.....:......:...............f=oundation . - .....:..........:.:.. Prop, line ............. . 0�0 LEACHING LINE ""-'�• ] . .No. of lines ...................... Lengthof :each line.............. .. Total length 'D' Sox ............ Type Filter Material ....:.............. . _............ . . .Depth Filter Material Line Distant, to nearest, We#I " f=oundation SEEP. AGE PIT O Depth : . r ................... .... Rock Filled� Y..................... roperty ne :.. p .................... Diameter ................ Number Water Table D ptli' ., . . ......__.. ocs o ...... "._...:-•-•- ....hock Size .." a �❑ +, ebistance to nearest, Well ....::: „ Foundation 7 REpAiIR ADDlT + Prop. line, ............. / ION(Prev. Sanitation Permit ^ .... '`''' Date ..... .... ....:: ...........I F (Septic Tank (Specify Requireir,ents , ''"•� . - . .. . # 1 'Disposal Field (Specify Re uirements ' ......... .' ' ..... .....i ' a .........................5---..............._._.._.. ............. ................ i................................... ......___a ...................... f ..... __ (Draw existing and required addition on roverse side} + f hereby certify that I have preppred this OP plleation and th at the work will..be done In accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- sed agents signature certifies theloilowi'ng: i I "I`certify that in the perfo anteof the work'for which this permit is Issued, I shall not employ any person in such manner as to become b(ect to rkman's om ens tion laws Cplifornfa." c o, p Signed :....._. . �..._._�.. , g }. = d t i By ............... -- ._.... :�t . Title . N ` ' :•• .. --- . -• (If other than owned poi: i . DEPARTMENT USE ONLY 'f APPLICATION CUD BY ..— BUILDING PERM TISSUED ............ ... DATE ..Pr. .. � ............. ` .................DATE ADDITIONAL COMMENTS ........................................ ...... ................... ..........................................................................y.................... Final Inspection by. ..... ..........�1: ... ............................... .----•......--- .................. .._.................................................. ...... ......................................... ....'..... ......' ......................................I. ......... • ............................Dote r'.1.•� '��`p.:.........--•--...,..--- SAN JOAQUIN LOCAL HEALTH DISTRICT �.. E_L1 13 24 t.•� a... c�a