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FOR OFFICE USE:. APPLICATION FOR SANITATION PERMIT �S "�� r �...t ............... Permit No. (Complete in Triplicate) . ................................... % Date issued 1 ? This Permit Expires I Year From Date issued .............. an Joaquin Local Health District for a permit to construct and install the work herein Application is hereby made to the S Nov 549 and existing Rules and Regulations: described. This application is made in compliance with County Ordinance • .....CENSUS TRACT .__...............jnr� J'•. JOB ADDRESS/LOC TION ,. ''" one ... ... Owner's Name ..- .:.cnru... Address ...- . ................................ City - - - phone ........_ ......... Commercial # ........ Contractor's Name . - _ . -Lic Installation will serve: Residence ❑Apartm t House❑ Ca ial frailer Court 0 j Motel C]Other - Number of living units:............ Number of bedrooms ............Garbage Grinder ........-- Lot Size -- .--------- --.. ". .-..----••-•................Private ❑ Water Supply: Public System and name ...................... Character of soil to a depth of 3 feet: Sand ] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Cloy Loam Hardpan ❑ Adobe [] Fill Material ............ If yes,type (Piot 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,) Size...l_ D0. •----.._-... Liquid Depth ........................ •- PACKAGE TREATMENT ( ] SEPTIC TANK t ] f - -- -- V' Capacity 2.Vre..... Type _ . ........ Material...................... No. Compartments __......---••---•..._. �1 ......._...Foundatio .. Prop. Line ......... .._ Distance to nearest: Well .............. - ( Length of each line._-. Total Len th 96L................ No, of Lines .-- I '--- - g ( LEACHING LINE ( ] ¢ `D' Box ............ Type Filter Material ...... Depth Filter Materia .......................................... Foundation Property Line ........................ Distance to nearest: Well SEEPAGE PIT [ ] Depth ---.-2.j ..--... Diameter 633........ Number --------/•---------------- Rock Filled Yes j&- No � Water Table Depth ..Rock Size .�-�C. ................. '_ _---------••--------- . Distance to nearest: Well .........----------------.-••••----••••• Foundation . Prop. Line ----------------•----- .. REPAIR/ADDlT10N(Prev. Sanitation Permit# ............................................ Date ...................... -- --- -) , Septic Tank (Specify Requirements) --------••-------•--------• ........................................................ Disposal Field (Specify Requirements). --------------------••- --------..... .............................................................. --------------------------------------------------------- - (Draw existing and required addition on reverse side) ; i 1 hereby certify that 1 have prepared this application and that 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 liven. i 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 any person in such manna* 4 as to beta a bject W rkman's Compensation laws of California." Signed . ........_ Owner - - Titie ........ ... ... 4 a �,s (If other than owner] i FOR EPARTMEN USE ONLY APPLICATION ACCEPTED BY -------- •• -------------- DATE ./.-..... -----.7__.i...... BUILDING Pl:RM17 ISSUED ....- ..:..............DATE .-....._..__...... :.. ----.-- i ADDITIONAL COM NTS ... � ..._ ►d /.C.L-__Q -� ___........ ._ .............. . .... .._...... ...... -------- ----- Date :rev. .. .,/ � Final Inspection by: SAN JOAQUIN LOCAL HEALTH DISTRICT /7z 3 M