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TOR OFFICE USE: �6 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT t Permit No.. ----------------------------------- (Complete •in Triplicate) Date Issued_6' This Permit-Ekiiires 1 Year From 'Da te Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County0dinance,No.549 and existing Rules and Regulations: JQB ADDRESS/LOCATIO,N........I-- `�_ _. . -- ..------�'1_Gt] _.� n.CENSUSTTRACL___ ----- Owner's Name y ' - hone -� �-7_. Address------------------------------------ .__ t.k�_.c.`� �'2.f� GtYL� Zip r ` Contractor's Name- -------------- S-0.11�:__-- License Installation will+ serve: Residence ,' �-Apartment House..[ Commercial ❑ Trailer Court ❑ Motel❑- ' Other--- ------ --- .;.-- .,... I_Number of living units__ __ _________Number,of bedrooms _:_._-Garbage Grinder_ ) _Lot,.SizEi - Q. l C.]i _._.__. ---------- s Water Supply: Public System and name --:--::-- ..:- :`------------- - -------Private . E Character of soil to a depth of 3 feet: Scind ❑ 'Silt❑ Clay❑ Peat ❑ Sandy Loam --Clay Loam ❑ 4 Hdrdpan ❑ Adobe ❑ Fill Materia .... yes, type..'____ ':__�_.E:__ 4 {Plot plan, showing size o Plot, location of system in relation to.wells, buildings,'et�c.=must beiplace-d:on reverse side.] NEW INSTALLATION: {N_o septic tank or seepage �pit� ermitted'if pul7lic sever is available within 200 feet,) PACKAGE TREATMENT [ '] SEPTIC TA�1K_[,] Size_____________ _ _ __ "'_"' _^'� _ __ Liquid Depth._ - ----- J - -t.+r �C-apac:ty -Type" =_'--------__Material__ -_ --------------t,No. Compartments----- -- t--- Distance to nearest: Well _------Foundation -4 �'":___ _.R'rop rLine___________________.____ L k 1 ------- LEACHING LINE: [ ]. -.Na. of Lines.:------;------.------'___-- ena�f etlr.�i li e.-'.--- -------'- � TataL Len th *------------------------------------- .4 ------ ------ ------------ LEAC 1 : `D' Box .__.Type Filter Material. - p F:Iter Matenal --------------------' __________.._______ i Lot Distancenearest: Wel! - _. Found - '_ P,ro erty Line------------------------------------- SEEPAGE PIT [ ] Depth----:.__ --Diameter.:...... . _Number_'_____________ _____ � Rock Filled Yes ❑ No - -- - Water TabDepth__________________________ Rock'Size------------------------------------------------- le4 , i v t Distance'to neaest: Wel—`"r._ - _: "='-F,oundation- --_ _.=Prop. Line-------- __ _� � REPAIR/ADDITION (Prev. Sanitation Permit-#-•� ---------------------------------------____Date-._ _---- Septic _ �.;�-�--T:__._,.;;.__ R :. .• �'"'` �"'� -- Se tie Tank Specif Re uirements ' --------=---=�- ---- ---- ---�'=,�-�r.J:___�._-:��: -1-� ------------------1--- ---, Pp 1 [ p c yq ----- E,X: S�i � �� - r 1F� :�= �"---- ----- Dist Disposal Field S ecif Requirements)_____________ I � ��` �` -� - - 4 } -� �_ ' n `Wad -'--: ` , -- - - = f (Draw existing and required Mclition,on reverse side) I hereby certify,that I/have prepared .this application-and that the•work will be�donee in actor dance with San' Joaquin -County Ordinances,lState Laws; and Rules and Regulations oV the San Joaquin Local Healtli District, Homekownerlor licensed agents signature certifies the following: r- ! ")'certify that in the'peiformance'of the work for which this permit is issued, I shall not employ any person in such manner as to I become subject o Workman's`Compensation laws of California." � - .. - -OwneJSigned------- Y`- {If other than owner) ' FOR DEPARTMENT MENT USE ONLY APPLICATION ACCEPTED BY- - ------------------DATE -� --------------- DIVISION OF LAND NUMBER----------=-----------------=------------- -----:---DATE- ---------- ----- --- ------ --= ----- ADDITIONAL COMMENTS- --7-------------------------- -------------------- -----t-------=------------------=---------------------------- ----------- ----------------------------------------------- - ------------------=--•--------------------------------•------------------ t Final Inspection by:----__---------- Date.-6- EH 13 24 SAN JOAQ IN LOCAL HEALTH DISTRICT F677 REV. 7/76 3M