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•Yn. , ^FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ?� -------------------------------------------------- --- ---- Permit No.__7i___-3r� Y Y (Complete in Triplicate) J ---------------- -------------------- Date Issued.------- -_ �.. ---------------------------------.--------------- ___... This Permit Expires 1 Year From Date Issued i 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 County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION....._[- U 11---------!;1�7---Af- y,Rte'---------19411-C---------- -------------------CENSUS TRACT ---------------- - ----------- Owner's Name.'. _ - .------ ------------------------- - -------=-------- -----Phone- ------------------- --------- --- ��' ---- ------------------Zip------------------- ----------- Address -�-�1�--- �.� --L-''---�.��P�'.�.,0'¢-- ---.../�,�3L1��-------- ---. City.. - `� Contractor's Name. /�7_ .LGi+]., 'irk--- �1 / l�' ---- 't'9%__,�.N� ---License #_-- -X61• .'"------Phone =--�' '�� Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ �( Motel'•Q Other..- ---------------------- ---- --- ---------- t Number of living units:__..:-J.-------Number of bedrooms-----3----Garbage Grinder.........-_,jot Size . ,a AZV,1?A-7-7h! Water Supply: Public System and'name------------------------ -------------------------_.--------------------------- -------------------- ------------------------------Private Character of soil to a depth of 3 feet: Sand [] Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ y Hardpan ❑ Adobe]W 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 public sewer is available within 200 feet,] PACKAGE TREATMENT ( ] SEPTIC TANK . D Size--- �._____��- '�L-4^ ------- -----Liquid Depth----- _____________'v Capacity-1.227.0 Type----------------- Material "-No. Compartments --- ------ ------ Distance to nearest: Well-------- _04-------------------------Foundation_!=__.-� -------Prop. Line------ ----------- --� LEACHING LINE [ No. of Lines...._____I-----------------Length of each line._f... _ a____- .'--Total Length .__ _rte. _____...-:_-r.--------- - 'D' Box-----X_---Type Filter Material---ifd4 '____Depth Filter Material--.... ----------- --------------------------------------- ¢ - E &&,Property Line------ -��'� �---------------- i Distance nearest: Well.:-___� __,______...--Foundation._- __._....._ - :•SEEPAGE'PTT [ ] Depth.---------------Diameter_.:___e1--------------Number------------- = -- ---a• Rock Filled Yes [�4 No s -.41Nater Table Depth. --- = F ock S ze'-r_'-r :`--�--- -- ---------------- r -- ---- R - IF 1 Distance to nearest: Well....___.'_-.-'.`- ------.: .- --Foundation.--�_s:- --....Prop. Line______-_____-------------- • S REPAIR/ADDITION.(Prev. Sanitation Permit#-------------------------------------" Date..______= r_---------.-------------------1 Septic Tank (Specify.Requirements) / G-G �'444L w-'h-' - --- -------=== - ----- -------- i e i"4 Disposal Field (Specify Requirements) --"_'- --=- ----------•-- ---------------------------------------------------- -------------------------- ------------ ---- ----------------------------- ---------------------------- ------ ------------- -----'--- ----------------------- -----------------_------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I 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 the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: ' "I certify that i the performance of the wok for which this permit is issued, I shall not employ any person in such manner,.as to beco ject ovjwkkan's Compensation laws of California." Signed- ---------------- , ----------------------------------------------Owner By f :. -'------------------------- - ...Title----- ---------------- ----------------------- --------------------------- _ (If other than owner) FOR D PARTMENT USE ONLY 101, F APPLICATION ACCEPTED BY_'._ - DATE.----�J.. DIVISION OF LAND NUMBER-------=- ----'---- - - DATE. ADDITIONALCOMMENTS------------------------ ------------- --------- ---------------------------------=-------- ----------- --- -------------------- ---------------------------- ----------------------- ---- ------- --- ---- ------ --------------------------------------------------------------- -------------------------------- -------------------------------- --------------------------------------- -- = --------------- ------ - ----------------------- ----- -------------- - Final Inspection by:---, --------- --------------------------Date ---- : - 2 _ �� EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. 7176 3M