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fOR OFFICE USE: AMICATION FOR SANITATION PERMIT Permit No. .-..7:7..:_ y, ------------------ (Complete in Triplicate) --••.............••---•---••-..-----�- (Comp .. _ r .. .. . _ sued �.__. •. - . - Date Is ............... ... This permit Expires I} Year Prete Date Issued and all Application is hereby made to the Son Joaquin Local Health District dtnarncae No. 544 and existing rmit to Rules tand fiRegulot onssein pp ; described. This application is made in compliance with County . (� CENSUS TRACT ............... . JOB ADDRESS/LOC TION •-4- . . � .....Phone Owner's Name - :*�..... / ............. Address . .. , ` - ::City . \ .. - ..License .... Phone jr ... ' rector's Nome .. - r Cont I installation will serve: Residence❑Apartment House]'Commercial flTrailer Court Motel Ot er - -•- ` -� .....:,. Lot Size ... ' ... ( Number of living units-._!...... Number of a rooms •Garbo- a Grinder i ....... ..... .... Prlvafe Water Supply: Public System and name .-----•........•.................... dy Loam 0 Clay Loom f Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay 13Peat❑ F Hardpan Q Adobe C1 Fill Material ............ if yes,type ........................... ..:,_.rte �.- `'""(Plot 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, 'j� Liquid. Depth SEPTIC TAMC Size.. ��— PACKAGE TRI=ATMENT, [ ] ..... No Compartments ..•-- Capacity�.O.�.0 4.. Type .6.--� Materiol... a � a 15' ti F Well �®... . ---•`�_'.......:.Foundation �j--� Yotal Prop. pth• 7Line �.•... ........... .....:=#o nearest: ..Distance LEACHING LINE No....of Lines., ••-------• ......... Length 'eachline. -/ Depth Filter Material ......:� �........... .........--•--.-.-•- .... D' Box .....•-..... Type Filter Material . Distonce!to nearest- Well ..� ` --.-••-•- Foundation ..-....��....--:.... Property Line ...... ....Q. ` ` Number .-........ Rock f'lled Yes 2(R No 0 . Diameter _.. -- ---- SEEP� A� PIT � Depth -- --------- --•- f ..Rock Size ...... < Water Table Depth ...--- r � , s ...... ....... Pro Line ...... ......... Distance;to nearest: Wel! -.��----------------------- foundation- .. -.... .... P• - . Date REPAIR/ADDITION(Frau. Sanitation Permit .-•-•---�••••---- - - I ••-- ............. .:...--.....................••..........--- Septic Tank (Specify Requirements).........................••- --- - ............... Disposal -Field (Specify Requirements) ---•------------------ -•-- ...........----------------------------------: ........... •...... -•-------- ----------- ... - . ........ ll _ ---••----------•-----------------•--.....-. - ---------------------•--- --------- _(Draw existing and_required addition an reverse Si a�„ ;;, .,,�. - --• - »ate I hereby certify that I have prepared this application and that the work will be done It attardance with Sanh:District. Home owner eoaqu n ` County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Hear licen- sed agents signature certifies the following: arson in such manner "I certify that in the performance of the work for which this permit is,issued, l shall not employ any p as to beco subject t orkman' Com nsation iayrs of California." ' �.-....- OwnerSigned -.... i .g -----------•- -----.-_----- ., .. --- ........... .-- Title (Ifth oer than owrierl ' f FO EPART T USE ONLY DATE . 'r'..: ... ... APPLICATION ACCEPTED BYE- -•---- . �• ---- - .. _.: -..., ..4 . .. -----••��----,. ----•-DATE ..........:............................... f BUILDING PERMIT ISSUED -..---•---- •------- •-- ----- ........--------•• ..-..-... ADDITIONAL COMMENTS ---------- ----------- .....------......----------- -----....... -------------------------------= ------•----•--•-••----••-•-........-.--.... ----------------------------------- - -•-•.. ...... --- D I final Inspection by: .------- EH 1.3 24 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8�7l, 3M