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r - FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No.. - 'T . _-- I s �I .� Date Issued-._--.__�%--- % _ _ This Permit Exp es -1 _Y4dr`Fr6m Date:Issued •-- --- --;" ------------ -- ---- - - - Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describe I This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: r JOB ADDRESS/LOCATIO ... 4':7 /..__q'--_ - , �'----- --- -- -_•_.._CENSUS.TRACT.-----....---------. Owner's Name. ; .. ' j.. Phone +� / i {' Address - :-._.. / rR , -: ------ ,I f�/�y -- ---- City.._.. Zip - -.c. 1 4 Vie! F i ns - ? - -- ---..------------ Contractor's Name-:... L'ce a Phone Installation will serve: Residence ❑, Apartment. House. Commercial ❑ ~'Trailer Court ❑ 4.,Motel ❑ Other---- - Number of living units_________________Number.of.bedrooms ________Garbage Grinder _:_.---:._Lot.Size-._...'--.--T.__._---- _._.--._.._.._ ( ' Water Supply: Public System.and'nome--:.:--:`---- --=------ ------------------ :- - — -- - ---. ----. ------- - Private � P Character of soil to a depth of 3 feet: , Sand 0 `•Silt ❑ Clay E]' Pdat ❑ Sandy Loam E] Clay Loam _ ... � � Hardp a art � Adobe Fill Material___.; ---- ..If yes, type___. .......... --'.......... i (Plot plan, showing 'size of lot, location of system in relation to wells, buildings, etc. ;must be placed on reverse side.) _ I NEW INSTALLATION: (No'septic•tank or see 'de pit permitted i publicewer is av ila' le' within 200 feet,) j PACKAGE TREATMENT (] SEPTIC TANK � ` Size. -S -"/J _7 j%crti'"�---: ------ ----Liquid D'epth._._7.__ . -------4 Capacity yP i --- --- --- ©� T e -=Material.:4-!!ti�-C.r--. No: Compartments_?-._-`�c------ Distance .to nearest: Well.:— ------ 1- 0.Q_._--_.-_-:------ �Foundation_,__:_1'Q-.�.._..._. Prop. Line.--: 1 i / '< ` LEACHING LINE, ( No, of Lines_ -------`, !,:.__...,:...__Length.of each line Length— _.Total Length __.._©-- D' BOX"'- i_Type Filter Material`____ S_ _.Depth Filter Mate ial._____Iq t Distance to nearest: Well-:._ _t-__.-:__.__Foundation_-__.r{__�.._____.-__-_-- Property Line_:___-. •� .__ �_._--------- SEEPAGE PlT [ Depth________________Diameter.:-_. -._-_._._-_. umber-___..-_- Rock Filled Yes No ! © Water Table Depth = = Rock ;Size - t -----. ------ t.. Foundafion_...�_Q_�.- Pro Li'ne� Distanceao nearest: Welf:"!.��. _--------------- P• REPAIR/ADDITION (Preva Sanitation Permit #__-Date.__ ......... __--_------ ...... - ----1 Septic Tank (Specify Requ}r.ements)_ _.�......__..•.._.. )------------- ---------::-------------- ------ ----- --- - L: Disposal Field (Specify Requirements) ----- -------•---A -------------- ---•-•••-=----------------------- ------ --------------- ------------------ - --------------------------.:..... -= = ' . - - ... , ----- 1------ -- ------------------------------ --------- ------ --- ---- - ------ I raw_ezisting and required addition on reverse side) ' u $ ! I ). hereby certify that 1 have prepared this application and that the work will be done in' accordance with Sail Joaquin Cou Ordinances, State Laws, an`d-Rules `and"_'Regulations~of. the}_San Joaquin LocalHealth District. Home owner or licensed age signature certifies the following: "1 certify that in the performance of.th6 work for which this permit is. issued, I shall not employ any person in such manner to become subject to Workman's..Comp nsation laws of California." .. I Signed__...-..:.__...:. - ------- ---- - ---- --- -- `Owner , ...--•, -- - --- --- ---- --- .Title----- ---- = -- --- - --- ------ - (If 'other than owner) FOR, DEPARTMENT USE ONLY APPLICATION ACCEPTED BY., DAT DATE I DIVISION OF LAND NUMBER ----•-- ---- -----------= -- = E ::. - -- �- ,. I ADDITIONALCOMMENTS— ----------------- -----___ ---•-•-------=------------- ------ ..------- ------- --------- ----- i - ------------ - ------------ ----- .................. -----------------------------------------. ----- -: -- -- ---------�------- ---- -- ' - -- - ---- - • --- - - Final Ins ection ,b - ---- Date PN ,1 9d ' cent inenl II I nCAI HFAI-TH DISTRICT F8S 21677 REV. 7/;