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FOR OFFICE USE: �/ FOR OFFICE USE: Y APPLICATION FOR SANITATION PERMIT --------------- ---------------------------- - �� -i Permit No.7r�� [Complete in Triplicate) - ------------------= -------------- -------------------- Date Issued)/_.7/,e9-,7'.,iir -------------------------------------------------_.----- This Permit Expires 1 Year From Date Issued Application is.hereby-made-to the San-)oaquin Local -Health District for -permit•to construct and-in-staII-the work*iEreiw described. This application is made in complia with oujd�Zce, N and existing Rules and Regulations:✓� C --�1 - 5 CENSUS TRACTJOB ADDRESS/LOCATION-- --- ----- - ----- ---- ---- --- ----------- -- - ---- �- . Owner's Name _-x - -u.►" •� - !� - 'f"" - =_ Phone----------------- -----�-------- Address Z� 4-----r-------.._ -- - City �CC 'a Zip s'x _ate% i Contractor's Name------ . --- - -License #_, Phone----/� I .4._ . : .. c Installation will serve: Residence ❑ Apartment House ❑ Comm tial Trailer Court E]Motel ❑ -Other_- �, ±--- --- .. .- Number-of living units:-.,-------------Number of bedrooms-------:_—Garbage.Grinclar.....__..__.-Lot Size------------------------.-------------------- ..___.__.__- Water Supply: Public System and name---------- =---- -- -- ---------------- -_Private ❑ (/" Character of soil to a depth of 3 feet: Sand ❑ ilt❑ Clay E] Peat E] Sandy Loam E] Clay Loam ❑ I 'Hardpan ❑ Adobe Fill Material-._._-__ ---If yes, type------------------- ------------ (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 publics ewer is available within 200 feet,) 1 � Size '7! ' ;(. �2-'- a-PACKAGE TREATMENT SEPTIC TANK Liquid Depth _ - ° Capacity,&w Type-- Material. '--------No. Compartments----- -------------------•-•---- ---------- Line_: _ _--- - Ll ACHING LINE [t� No. of Lines.............. ................-Length of each liria._._:___ _ _ -----_.Total- Length Sao-g P 'D' Box1__1"--Type,Filter Material Depth Filger Material--:__la ------------------------------ ------------- Distance to nearest Well_---_-_14 Foundation I o Property Line boo [ r f SEEPAGE PIT Depth----i.---. Diameter- .-- ---__-..Number_______ _ ________ ____ '_ Rock Filled Yes E] No❑ .. y = o -Water Table Depth.- ------1__----------- ---- __._ ------___ Rc iz -` i .. Foundation -.Pro Line----------------= Distance to nearest: Well_- -_..._.-------------------------------- p. REPAIR/ADDITION (Prev. Sanitation Permit#._* "------;----_'---- "---__'.Date.=`::_E-------=------------------------------1 Septic Tank [Specify Requirements[._-- ---.___ i - ' . ------------ -------- --- -------------------=----------------------------- E, } Disposal Field {Spedify.Requirementsl--------.._ `'�-- - = -= =4. _= [ ------- - - ----------------- ------------; ----------- ----- --- , _ ------- -- -----=---------------------- = -- = ..-,f� .i- `tea (Draw existing.and required addition on reverse side) � 4 ^* I hereby certify that I Have prepared thisapplication and•that the'work will -be,done.,in accordance with 5an 'Joaquin?G Ordinnceaw as,-'State ls, and Ruleand R6gulations of the: San Joaquin,Local Health-District. Home owner or licensed ag . signature.certifies the'f�owing: f "I certify-th?it-in-the performance of theyork for-which this permit'is,issued, Y shall not employ any person in 'such mdnner as to become`sul5ject to. "Warkm' dn,s nC pensation,laws .of California." - i. -- F t - ---- 4 ' Signed -- -----------=------'- " ------------------- ---- _. wrier nn 13 -u_--- ---- Title - Y ------------------------- y (if other than owner[ FOR-DEPARTM SE Y'.. APPLICATION ACCEPTED BY----- -------------- ------DATE.- -1_- �_ sl ------------------ DIVISION OF LAND NUMBER-------------- - ----- - ------------ _. ------DATE-------------------- -.---- ---.---- -- ADDITIONALCOMMENTS-----=------ --------------------- ------------------ ------ ------- ------- --- ----------------------------------- ` ------ --------`. - - ----------------------------------------------------------------- --- = = - -- --------------------------------------------------- - ----- - ---- -------------------------- Final ---------- ------ ---- -------------------------------- = - /. Final Inspection bY:.--�---_.-.----------------- -------------- -----------------° _---------- --------- Date--- - i EH 13 24 SAN JOAQUIN LOCAL HEALTH DI ICT F&S 21677 REV. 7176 inn