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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT = Permit No. (Complete in Triplicate) ' . ........ Date Issued ............ This Permit Expires 1 Year From Date issued l the work Application is hereby made to theSan com Iia Local ecwithealt u District Ordinance permit and existing Rules tand Regular ongrein described. This application is mode P '....................CENSUS TRACT .........._... . /10' .: _. .. Y.. .JOB ADDRESS/LOCATION F. Owner's Name •-•--_qq... - -- ............ j .f."_ ._..._. City .. .............. -•--- one Address ........................,�,�, s. - -1,C ,..- .License,# ��Plione Contractor's Name ....__. =---...._ ... . . . _. ._ Installation will serve: Residence T[�Apartment House] Commercial ❑Trailer Court Motel ❑Other ----------- ----------------•... ..`..... Number of living units:.___.__.:" Number of bedrooms._..... Grinder ___..._____ Lot Size .._. --- . .............iJ' '"-------- Private [ F Water Supply: Public System and name-------------------------------- Character ------------------ ------ - •- Character of soil to a depth of 3 feet.q Sand . ilt❑ Clay ❑ Peat❑ Sandy Loam❑ Clay Loam C3Hardpan Adobe [3 Fill Material ........... If yes,type ---------------.--------•--- (Plot plan, showing.size of lot, location of-system in relation to wells, buildings, etc. must be placedeE� reverse side.) NEW INSTALLATION: {No septic tank or seep ge pit permitted if public sewer is avollable within 200 ,� Z 6 Size.s....X_.l:a.. x ��... .... Liquid Depth...'............. PACKAGE TREATMENT [ ] SEPTIC TANK .�� �. Capacity -- b -._... Type X" ' Material_ c -.. No. Compartments i �..�...._. Pro Line S Distance to nearest: ,Well ._.._._ --"--•••- --..Foundation ...,�. P .... ... t7 No. of Lines Length of each line._ - Total Length ...l r _: LEACHING LINE N Opl " Depth Filter Material �" Distance to nearest: Weil -•••--�---- . Property Line D' Box .._�. ___..._ Type Filter Mater Foundation P rtY .` d Number _...--•----.�------------ Rock Filled -Yes. No [j SEEPAGE PIT [ j Depth -'_-.2•S••"••-• Diameter ._ w Rock Size Water table Depth Distance to nearest: Well ...:_.... 404 - ...Foundation .-/0.--_----. Prop. Lin . y REPAIR/ADDITION(Prev. Sanitation Permit# ..................... ...•-- Date Septic Tank (Specify Requirements "-.-•••-----••••----- Disposal Field (Specify Requirements} .:............:............:......... ------------------------- ...............-•- ---_... .---•----•---... .........I-----------------------------------------------------------------...---.._.....__...... .--.--------- (Draw existing and required addition on reverse si d e) . I 1 hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin ` nd Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- County Ordinances, State Laws, a 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 become subject to Workman's Coin ensation laws of California." Signed ............. Own ��• _ ergg� -------••......................... lir.-C" . title __� . ... ........ ........ . ..............•--- _ (if other than owner) I 3 FOR DEPARTMENT USE ONLY DATE ) 4 APPLICATION ACCEPTED BY - •......_... .......... DATE` ....................... ----------- .__-_'..... z 1 ... ---- ----- -•-------••.............. 1 BUILDING PERMIT ISSUED ADDITIONAL COMMENTS - y........:.... ..... .... ................. .............................................. Date.—I:a:y ...?.. Final Inspection by. ---.1— SAN JOAQUIN 10CAL HEALTH DISTRICT I 7/]23 M �J4v