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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT . r . == 3 IC o plet*in Trip cote) Permit No. .�:�� ...................•-••-----•-••--------.._... j .._, G!r'/' ndf�rtti Itr Date Issued ..............7 :.-•--••-•--•-----••-•-_--•-- This Permit Expires t Year From Date ss. Application is hereby made to the S Joaquin Local Health District for a permit to construct and install the work herein described. Thiss li a ion is mo lionce with County Ordiri nce No" 549 and existing Rules and Regulations: 168 �SS/L LTi N �f ` �� r .CENSUS TRACE .......................... .....,... IIL r. ...: �I !J......,•• f.....Owner's Name . .._ --- Phone � City . 6'.... . .... .Address Contractor's Name ----- •... . . .. . ..............................................License # Phone l .S...!. /..... Installation will serve: Residence WApartment House❑ Commercial ❑Trailer Court Motel ❑Other........... ................................ � , Number of living units:..._.___ Number of be room ....Garba a Grinder............ Lot Size .. __.... .............. � r Water Supply: Public System and name Private ❑ j -- ------- ................................. Character of soil to a depth of 3 feet: Sand Silt❑ Gay ❑• .Peat❑ Sandy Loam Cl Clay Loam ❑ t Hardpan❑ Adobe ❑ Fill Material ..._........ If es,type ............... ............ 6.. IPlot 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 pre Witted if public sewer is available within 200 feet,) C!1 PACKAGE TREATMENT [ ] SEPTIC TANKfpK Size.��X.. ................. Liquid Depth --. .�/...._............ s, Capacity V ...... TypePlu Material.&^.."-,.,....... No. Compartments ....A�-.....-_--_. �L Distance to nearest: Well __-- _ - ..................Foundation .-f.Q.....:....... Prop. Line -- -•-- ......__._. LEACHING LINE No. of Lines ....j_.............. Length of each Total Length ..;�ZO.............. 'D' Bax '� Type Filter Material � Depth Filter Material �6..........................c... Distance to nearest: WellFoundation .--14. .......... Property Line .. ................ SEEPAGE PIT j ] Depth Diameter ................ .Number .._-----•---.---------_- Rock Filled Yes ❑ No 0 Water Table Depth ............................-...................Rock Size .................................. Distance to nearest: Well ......... ..............................Foundation .................... Prop. Line ....... _ REPAIR/ADDITION(Prev. Sanitation Permit# ......-_--•- ------------------------- Date ........------------_--------.--) -: v �'L SepticTank (Specify Requirements) ................................................................................................................_-.............-............... Disposal Field (Specify Requirements) __•_------.--- ....................... ---------------------I........--------- (Draw existing and required addition on reverse side) I hereby certify that I 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 San Joaquin Local Health:District. Home owner or licen- sed agents signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to hesect to orkm n's Compensation laws of California." Signed -IUS-1-1 .'_: - -------- -------- Owner By By ---- --- ----•--------- --GtJ------ -------------------------------- Title ----'.--!— - ------------ - I llf other thaW owner) f FOR DEPARTMENT USE ONLY .r.S Z �. APPLICATION ACCEPTED BY ..... - - - - -•-- - - ---•------- -- ----------------------- -------------- . - -_-,.. -• ----- DATE - --- -- = BUILDING PERMIT ISSUED -----------•--•------ ---• --.DATE - - -----------------------------------•-. ADDITIONALCOMMENTS --------------------------..........---------------•---------------------------------- --------------------------• --------............................----- --------•----------------------------------- ----- ------. ----------------------------.--:---. ---------------------------------------•-•...--...-..----------•-•.............................. ._..... .. .------------- a ..............•-- ----. _..D ............ Final Inspection by: ' lel 13 24 1-68 1wv. 5KSAN JOAQUiN LOCAr�LYiI DISTRICT 8/7h 3M f