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FOR OFFICE USE: -u FOR OFFICE USE: APPLIC,'ATION-r01t SANITATION PERMIT ------------------------------------ ----- Triplicate) I -------- (Complete in Trip iratePermit ------------- ----- Date Issued. /.-5--,'$� --- This Permit Expires 1 Year From Date Issued ------------ Application is hereby made to the San Joaquin Local Health District for a permit to nstruct a install t work herein described. This application is made in compliance with County Ordinance No. 549 and exis g Ru� s an Regulat' ns: ,^ JOB ADDRESS/LOCATION- __ , ---- --lI- ---- ... SUS TRA �l eci G0 - --- ------ Owner s Name:--��--��---�-0.��-L i� -. d- -- -- _ T. � r Ity. i Y 1, /� �+� (,.' Phone -- --- - --- --- - Licen Contractor's Name- - -- ► ' Installation will serve: Reside ce _ Ap rtment ouse ❑ Co ercial ❑ Tr ' er Cort ❑ t - -- . Motel er-------------- ---- -Lot Size/A&.d-- �--i -------- -------- Number of living units:---`-- ------Number o e rooms-__---.Gar ge Grinde ---- .-__: r s name --------------Private E]and ----- - .1--- - - --------------- :-------- --- .---- ---- ------ -------._ :--- ----- Water Supply: Public System Character of soil toka depth of 3 feet: • Sand ❑ :Silt❑ C,lay Peat ❑ Sandy Loam X ,Clay Loam ❑ ;Hcirdpari ❑ Adobe ❑ Fill M a1 If yes, type > , s (Plot plan, showing size of lot, location of system in relation to`wells, buildings, etc.must be placed on reverse side.) ,-_ , NEW 1NSTAILLATION: (Nod.septic flank or seepage p- it permitted if public sewer is available within 200 feet,] x.. =Size f, ---A�i- -------Liquid Depth ---- --- ----- PACKAGE TREATMENT ['] " SEPTIC TAMC ['l { ; :T e----i------------------Material---- --_- `= No'�Comparfiments ----- Capacity-::^' - Yp -- 7 I_ - Foundation--- `-.Prop. Line-_ - --- --- --.5 Distance to nearest We.10- - -- ---- L �c ��_�r 1 .-Tota Length. / -r'>-------------------- LEACHING { _ LINE. [ No. of Lines-'--- ----- -., .Length of each lin, - �7��-� , _ . - fib- , _ � � { D' Bax_--Type Filter Mate al _ f ` ._.Deptk Filter Material----- ----- -------------------------------- -- --- i �`-.--- -------Foundation --`�` Property Line �� -- - Ca ] ance to nearest: Wel]�d--- _ - ' R k Filled [ ] p, 1 1 Dist oc Y s :- es No ❑ SEEPAGE PIT ; ! De th.v2-_.-- D'fameter_: - , I } � .. Size ' ------3----�--- - - ---- ---- ------- WaterTable Depth--- ------------------ - ------------------------- Distance#a nearest: Well.; --'--- - -.------ - ---------.Prop. Line te---�' � EPAIR/ADDITION (Prew-Sanitation Permit*,- _. - ----Da � -----=W'-- - ------- ----- Septic Tank (Specify.;Requirements)-----'- = -- --=-=--- ----- ----- ------------- >-------- --- ---- ---� =------ --- _ F ' 4 ------------ -- ------ Disposal Field (specify Requirements)-----------=----------- -------------------------------------------------------------------- j - " . . � _-------- ----- .--- ------ _ ----------------- - --- -------- ---------------------- _. y ----------------- -------------"'-_— r- = TZ ---------------------- --------------------.-----_---.-------- -------- :_ --------------- - ;,.�. ,�,:.. .- -�. r (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 Regula.tionslof the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: k "I certify that in'the performance of,the work for which this permit is issued, I shall not employ-any person in such mannerias to become subject to Workm n§ Compensation laws of California." -- .: Own,r , Si ned-- -- - - - r i } ----------------L' � - Title----- -------------------- (If of er'-than owner) ' r R. PARTME U ONL -F APPLICATION ACCEPTED. BY= -- ------- ---- DATE. ----- - - --- DIVISION OF LAND NUMBER ----------------DATE. :: - ADDITIONAL COMMENTS-------------- --- -- ------------------------------------------- --- --- -- - - - ---- ------------------------ -- - - _. --- - ----- --- --- __ - _ - ,_�_ ry t ------------------- - -------- ----------- ------ ----- - ° - --- -- ---- --- - -- ---- - - -- - - - --- ---- a 1 r '.�� .5 r.. -� ,.-- �-Da#e -- --- -- Final-Inspection-by:-. -r-- 6 3rn _ -- --ti , `' i F&s 21677 REV. 7/7 EH 13 24 SAN ioO,QUIN LOCAL HEALTH DISTRICT ��,Y _ r.