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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SAWiTATION PERMIT - ---------------------------- ------------------------- (Complete in Triplicate) Permit No. Date ate---------- -- ----------- ..... __-y=_._.____ This Permit Expires I Year From Date Issued 4 Application is he ebymade t tl San Joaquin Local Health District for a permit to construct tall the work h rein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations:_ { -----�.�/ - -GENS S TRACT ------------ 'Y.? _. _ JOB ADs NESS/,tiL C-TIO5Nf_...._. r ie / � Q d�-------------` -----.-- ----- --. Address /';> 1 - r �PsP/L, CYC` CitY .1 -----------------Zip--------------- ----------- [ x �Z� L CrldCi -------------------------License # �7-37_ _e.Phone. 7'_7-,174!.> a Contractor's Name.__.__. Installation will,se=rve: Residence t?5 Apartment House.❑ Commercial 0 Trailer Court ❑ f• ....;....,.: .Motel ❑ . .Other------ ---=-------------- ------------------- Number of living units:.____!_______Number of bedrooms____ Garbage Grinder.:__._:_._-�.Lot.Size._-.<_-_��j�_ �__________ Writer Supply: Publie�System and.name ------!` ��/�' � - ---------------------------- ------- - -----------------------P'rivate Character of soil to d depth of 3 feetSand ❑ Silt❑ Clay E] ` Peat 0 Sandy Loam E] Clay Loam•K �. ti Hardpan ❑ ' Adobe Q Fill Material.............If yes, type'--_______________.___.___._ {Plot plan, showing',si e of lot, locatian,'of system in relation to wells, buildings,_eetrc.`must be.placed on reverse side.) p # NEW INSTALLATION: (No septic't'ink'or seepage pit'.permitted if public sewer_is available within 200 feet,) s� PACKAGE TREATMENT [ ] -' ERTIC TANK [.1 Size__._ __JA I C r ." ___Liquid DeptH.=__ _C�_ ' a r- v t Caity-fa �J _7 pe- Material__CA' _No:�Com artments__r______;__________._-_�__._ -: p E Qistance'..to near.est:-Well-"._____ Q"Q__"_-„:-s- ” : _rFoundation_*-a�______________Prop. Line___--4: Z7___..___.__". ING LINE . &t:o,.f;.L-in-e�s- _��--------------Length ofi aachLEAC .. •� ' ------------- SaTotaI Length -- _- - : D' Box.-= Type Filter Materia l;_f __ ep Filter:Mbf6riol__f_-Z _____- __ t E)rstance'fo nearest: Well_=_ ______..___________Found gtion_-___.3 _ Property Line_________ _________------ ---- -- r SEEPAGE PIT [ ] Depth__A;Z--------Qiameter__',e. _ _._.Number__________________________ i ; Rock Filled Yeses] No'❑ ,Water Table:Depth--- '_" " = =- -- =----.Rock -Size--------------------=-------------------------- ------------- `�� i. �� i = ,. ,Distance.to nearest: Well.... �d -------- Foundati6ii-_-_� -------------Prop. Line_____ REPAIR/ADDITION (Prev. Sanitation..Permit,:#_----—-------------_______ _Date _ __'_-".__' � -'_____) ' Sept'ic'Tank (Specify Requirements) '-- !t7_' --- ---°, = o- . - - Disposal Field {specify Requirements): = , - = --z--------------------- --- ----------------- __"""_____ _ __..__ 3 ? __ __ ._ _____._ , ...... (Draw existing and required addition on reverse side) { I hereby certify that].have prepared this-application and-that the-work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules'and Regulations of 1 the San Joaquin Local Health District. Home owner or-Iic'ensed agents signature certifies the following: "F certify'that in"the performance of the-work 'for which this permit is issued, F shall not employ any person in such manner as to become 'subject to .Workman's. Compensation laws of California." Signed - ------------ -I-..--- . f ---Owner - :Title.- ------- -------- 7 Qv+.,- { (If 6th'er"than owner)= ,. I ' - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDrBY T - --- ---- ------ ---=------------------------------- DATE -- ------------- DIVISION --- -- t 1, DIVISION OF LAND NUMBER = -- DATE = ._ .: . .:------- -.:--.-------------------------- ADDITIONAL COMMENTS________________________ -------------- - -- ------- -- -- --------------------- ------------------------------ -----=---------------------- ------- ----------- -------------------------------------------------------- ------------- -------_----- ---- --- ____________________________ _ _----- _____ _ .__ ------------ ___. "_____.___T _._ _______...___.______ ___.._ Final Inspection by:------- ----- - -- =-------- -----------Date EN 13 24SAN J QU1N LOCAL HEALTH DISTRICT F&5 21677 REV. 7/7fi 3M