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rt FOR OFFICSE: 4 FOR OFFICE USE: -----(f,-OO-� 1--c t� AP CATION FORSANITATIONPERMIT "` �• (CompleFe i Tripe) ` Permit No.-7 7k - _ - - - }• ---------- -- - ---------- --- This Permit Expires 1 Year From Date Issued Qdte Issued_.._. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein clescribed.`='-' } This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ! JOB ADDRESS/LOCATION_ 15n,.;, --__:/_ ----------------------�LJ� C - --- ----- --- ] CENSUS TRACT ---------------------------- Owner's -------------- -- -- --- Owner's Name.--------- �,f.� ,j� . -- - --- - ----------------- ------ • •r ._ . - . ._ - Phone - Address-------------- --- - .... ----- ---- City_ - ---------------- dip Contractors Name-..__i _ . -1' License '# .-.7l / � --- -- / �-9- - hone_46�� b -3 w Instal lation.will serve: Residence! Ap'rtment House ❑Commercial Trailer Court ❑ { !Motel,.p Other ----------- I Number of.living units:____-------I�(urriber of bedrooms ! ._.__Garbs e GdndeKT._,-,-.---- Loi#.Size_.__-___. Water Supply: Public System •and!name--------- ---------- I t ,--Private _ ;..------�---- . '--- ---- ate k r Character of soil to a depth of 3 feet: Sand ❑ .Silt❑ Clay ❑ Peat ❑ Sandy Loam"'- Clay Loam ❑ U Hardpan ❑ Adobe ❑ Fill Material. ___.____lf es, ] '7 E Y type----------f-- - ----------- I [Plot plan, showing size of lot, location of system in relatioh to wells, buildings,-etc. must ie placed on reverse side.] NEW INSTALLA710N: (No.'septic tank or seepage pit permitted if public sewer is available within 200 feet,] .._. { ] —SEPTIC—TANK[;] ? r i-------------- Size---- =- ----- ------ - -- ----------- ---- Liquid Qepth--------- Capacity--- - c�•r-� Material:- ---- ----- - _No. Compartments -- t - -- Distanee to-nearest Wehl-�— ------ ---- ------ --------------:,- ound son t-_E:_q >.. Pro F at �_ _ ._ p. Line LEACHING LINE. No. of,Li.nes----- ---------------------Len th of each line, ------- --------:- -,,---.Total Length.----------- ---,---- ----- -----' 9 'D' Box------------Type Filter Material--------------------Depth Filter Material----------------- Distance�to nearest: Well-_--"_______________________Foundation.---_-___ _- Property Line-_:.____ .. .. ----------------------- SEEPAGE PIT [ ] Depth----------------Diameter._------ ___--'----Number --- ----------------------- Rock Filled Yes ❑ No� E : Water Table DePah = -' -- -.Rock Size_---- - t Distance to'nearesf: Well__: "___-_-`....:_ ::.Foundation"-'__.. ` Prop. Line ----------------- - Prop. REPAIR/ADDITION-(Prev. Sanitation Perrnit#-------------------------- }: f � ate -�=-- ------- ----- •----- --------f Septic Tank (Specify Requirements) ' --- - g, --=------- ; P ---------- ---- Disposal Field (Specify Re�ulrements]_ �� ,. r -------------------------------------------- ---------------------------------------------- 11-0116/ . - --- --------------- Qraw existing and required additioni,on ever. -------------- -------- se side) I hereby certify that] have prepared this application and that the .work-will:be done -in accordance with San -Joaquin Caunry Ordinances, State Laws, -and Rules"and Regulations of' the. S'an Joaquin Loc I Health District, Rome owner or licensed agenfs^ signature ce.rtifies the following: 14, x t 4 1 "I certify that in the performance of iflie-work for which this pe niit is issued, I shall not employ any person in such mangier as to become s ect to Wor � an's C pensation:-laws of California." t ' k t Signed - -- ---- _--- ----- - ---- ------ _ E t �. a Owner � Title (If other than r) rx FOR DEPARTMENT USE ONLY APPLICATION ACCEPT�IB;DIVISION OF LAND NU :- e ATE - TE... -�� ---------- --------------------------� ------ ------ -D - :------- f ADDITIONAL COMMENTS_____________ ____ _____ - ---- ... - --------------------------------- ------ -------------------- - ------------------------------------------------------- ----------•----------------------------- '- . l7 -------- - ; Final inspection by: � ' -------------- ---- -------------Date . ------' := EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV.