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FOR OFFICE USE: A (CATION FOR SANITATION PE 'r ti No. ....--�....�yp Permit .. . .. (Complete in Triplicate) 7 -- a bed S............J P.................. . This Permit Expires t Year From ate Issue and Ing the Application is hereby made to the San Joaquin Local Hwitealth DistCounty rict Ordinance permit t andexistingi Q Rules it Regulations'wooheein described. This application is made in compliance ia�n � i " .....J�J. S. -� t rra. ...................CENSUS TRACT ........ ................ JOB ADDRESS/LOCATION .- ...:. ... ...................... FIs ................ .:......... ......Phone ..,.. ... Owner's Name . . ........ �i C ............. . ... ... Address ............ city ............................... Contractor's Name .-.......-...-..-...-.. ... ........License # ........................ Phone Installation will serve: Residence ET-Apartment House❑ Commercial []Trailer Court ❑ Motel ❑Other -------- ................................... -----•••-••-•--••................. - lot Size _-•.Z....Gorba a Grinder ............ Number of living units------ ...... Number of bedrooms g Private ❑ Water Supply: Public System and name -----------------------•-•---•---••-.... .---.... .---- Character of soil to a depth of 3 feet: Sand ET,Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ ' Clay Loam ❑ Adobe Fill Material If yes,type ............... ............ Hardpan ❑ ❑ ......-....' (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,) PACKAGE TREATMENT [ ] SEPTIC TANK( ] Size...............•-....----••••--••-- Liquid Depth ......... C, Capacity Type -------------------- Material...................... No. Compartments ...................... Distance to nearest: Well -------------•--••- Foundation ...................... Prop. Line ......................V LEACHING LINE [ j No. of Lines - Length of each line.--------..•---•---- ...... Total Length ---.Depth Filter Material ........... ......:..............I.......... 'D' Box .---•. --... Type Filter Material ................ ---..... Foundation ...: {� Distance to nearest: Well ............... �--•� --��-�• •�--�-��' Property line ............ ...... 1 Depth Diameter --- ......... Number ............................ Rock Filled Yes ❑ No �] SEEPAGE PIT [ 1 p ........ .....•. Water Table Depth Rock Size ..........-...................... Distance to nearest: Well - ...------.Foundation --.. ....... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# Date .. .............. .) �' ' l Septic Tank (Specify Requirements) ......Ad 41un-..-,a-----.1C1C Disposal Field (Specify Requirements) ........................................................ ............................................ h (prow existing and required addition on reverseside) 1 hereby certify that I have prepared this application Regulationsthat of the San Joaquin Local done Health.District. Hams owner or I cern County Ordinances, State Laws, and Rules 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 becom ubj t to ark n's Compens�o 1 s of California." Signedx .. ..- .. G-lm. ----•- Owner i BY .. - ---------------------- Title -------........ .... -... ----------- --.......... --................. (if other than owner) FOR DEPARTMENT SE ONLY ..- .�.. G �1..--.... DATE .....5�1 = ......................: APPLICATION ACCEPTED BY -- ---- --•-- • ......DATE ........ • ............. ...... ......... R. BUILDING PERMIT l55U>=D ....................... . ........:....................... ADDITIONAL COMMENTS ----------------- -- - -- ------------------------- .....----- - ------- -----•--•- ---------------------------- .............................. :.... .......................................... ................. �:..� ... ,.. ......... -•......................... ••---------.-•--.....-------••--------••-.....-------•---...-.----......._.......... .-._..•.� .YT---...Date ...... �-?.�-........---........... Final Inspection b -•---••-- ---•........................................ ER 13 24 1-66 Rev. 5M SAN JOAQUIN LOCAL HEALTH RICT