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FOR OFFICE USE: FOR OFFICE USE: . _; APPLICATION FOR SANITATt6N PERMIT r ---------- ----------------------------- ." Permit No._7-7.!_�6 -- (Complete in Triplicate} ----------- -- b 717 Date issued - ------- --------------- Thi" Permit Expires 1 Year From Date Issded Application is hereby made to S n Jaaq i ocal Health Dis,rrict fora ring# construct F instalJ�fhe work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: q • --- JOB ADI?RESS/LOCATI N._ _:.,_ �-< R_.__,_r.: GENS TRACT.. . - Owner's Name------ - - ----- --- Phone_ _ _ .__. _ Pho S�� Address_. ------------ -------±----------- .• ------------- ---------. City----- - --------- --------------- iP Contractor's Name 0(iv/f. -=------------ -----;_-------------------:------------ License # `----- --- " P`h`one R}} I $ * Y menf House.❑ Com ercial ❑ Trailer Court ❑ e Installation,will serve: Residence ❑' A art Other--- - - .: .. _ � - —t E f � � , .....�..,4 Mot ' tiZ� . --- 7 7— 3 r� Number of.liv.ing.units:,_.:---__-------NurRr,of bedrooms___-;.....Garbage Grinder____._-.._.Lot,,Size-_........ .__ {e.:.__. i i -- j,- y ------------------ ---------.------- .:--'------ -Priya Water Supply: Public System and?name -_ ----- - ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay�` ea r '�La Clay Loam t❑ 'Hardpan r_ ANdobe ❑ atena . ------If yes, type---- ----------- ------------- (Plot --- ----(Plat plan, showing size of lot, location of: ysfem in rellltion to wells, buildings,'etc. must be placed on reverse side.] 1 NEW INSTALLATION: No septic tank br'see a e 4it ermitted if ublic sewer is avoilable•within 300 feet t Q� PACKAGE TREATMENT ( ] SEPTIC TANKQ t Size--! d- _ Liu�it 'Depth. Capacity YPe Material_. t :.' No. C�m T20 ments � -) Dis an oto nearest: Well .. ---=-__- °4;.,Foundat�n-, �f- "-- ---------Pro !Li ----------------------------- H j....'f.___t_ . LEACHING LINE �of Lihes ` -.----2 - -- Leo#,- LLeach fins.. -`_ '� tal`Ce�ng�th.�r_ � ---------- of _ N I' yp Filter Mae ial; 1 :.....Depth Filter Material.ryz.-.a-::..t D' Box------ ._..T e 71 D stance to ne esti . 1. -------- Foundation :-- V ....-Property Line.-_S' -- ..-._ __ .___ SE1rP ] Depth j_=/. iameter�. �I`llun erg ------------------------------------------------ D II Ye ❑ N .5 -`0` Roc Fi s o i Water Table Depth------------------ ------ ----------- Rock Size 4 D Distance to nearest: Well Foundation----------------- : .Prop. Line iv }, F REPAIR/ADDITION -4 (Prey Sanitation Permit�#_. = = ----------------------------- � = = -- --- ---------------='--.Date-- -=- ---- = --- " } Septic Tank (Specify Requirements) --------------- ------- ----- -------------- --------------------------------- ------------- --- Disposal Field (Specify Requirements.) -----------------==---= ------= -------------------------------- --- -----------------------.-------, -------------------------------------------------- -------------.---------------------.- ----------------- ----- ----------------7------- ------- = --- . - -------------------------------- .... (Draw , existinq� nd"required addition on reverse side) _ 1 hereby certify that I have prepared this applicationnd thi4t,tlie `v+Y�"ork will be done in accordance with San Joaquin Count Ordinances, State Laws, and Rules .and Regulation lof,t4 San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: '•I certify that in 'the per fornidnce of,the work for which this permit is issued, 1 shall not employ any person in'such manner as to become !Fbjpct to Workman`s Compensdtion laws of California " Signed. ----- -- ._ Owner B ------------------------------------ _ _ --------------------------------------------------Tit e----- -------- ------- --------- --- ------ ---- -- F --(If -other than:owner) y } # FOR DEP A T USE ONLY - : 7- . APPLICATION ACCEPTED: BY ------------- ---------------- - - - =-DATE ~ DIVISION OF LAND NUMBER:-------------- _ ::_----------------`--------------:_.---=----------DATE_----------------- -------- ---- ------ ADDITIONALCOMMENTS- --- -------- -------- --- --------------'--------------------`--------------------------_---------------------- ----------------------- - ------- -------- -------------------------------f- ------- - ------------- ---------""-`-- ----- ------- ----- ------------- Final Inspection-by------ ,.. ------- ---- - ----------- --------------- ---`----- --- ------------=-=---------DatefW_=_T{ 2---------- -- >_N 13 24 SAN JO UIN LOCAL HEALTH DISTRICT F&s 21677 REV, 7/76 3M t 6/>