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FOR OFFICE USE: -`- -. _ .. I /APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: }" {Complete in Triplicate} Permit No. 7g--. •------ This Permit Expires 1 Year From Date Issued Date Issued_/Q-- -.7� Application is hereby made to t an Joaq��ocal ea! District for a permit,to construct and install the work herein described. This application is made in c pliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION---- r--�- xTO--i - ------------- -= Owner's Name - -- -- ------------CENSUST RACT------------------------- --'- --- -------------- --------- "--- - ---- .---- Phone------ ------- --q55 Address-------------- ---------- - ---- ---- -- -------- --- ------ -------------Ci Contractor's Name_ i2�_l /.l°_ - ------ ------ --------------------------•-'----- ----- ------ ----License # 2�IGj- 19 Phoree_Jpg_'23 Installation will serve: _ Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court'❑ ' o w.M. .. Motel ❑ Other------ - ------------- = = g ►'�c l�S Number of living units:__-___=:--____Number of.bedrooms___-___Garbo eGrinder__--_____.__Lot Size________________ _ __ _ _ , --- ----- , . s i ater Supply: Public System and4name-------------- ---- ---- -- ------------- --------------------=-------- __Private El at of soil to a depth of 3 feet: Sand E] Silt El Clay El , Pear❑ Sandy Loam ❑�; Clay Loam ❑ _ ,. I Hardpan ❑ Adobe ❑ Fill Material _ - _._ If' es 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 spit permitted if public sewer is available within 200 feet,] CX PACKAGE TREATMENT [ ] ; SEPTIC TANK- Size f _ -_ _- _4- /_Z_: - Y ' -'� ail s _ [ l _ O ?C - _ _-_--Liquid Depth. -- --- Capacity TYPe C � �6WClZe f Material_____.-- _"----------- Compartments--=---------------- Distance;to nearest: Well---_-_--_.- -- - ----Foundation-------- U- , ' p p " f --- ro Line----------------- f L a. No. of ---------------Length of each line.-------- o�___-_- Wo LEACHING LINE -_.-____Tota! Length. ------------------ I .D' Box .,Type Filter Materia!_;___��'� __-_pepth Filter Material_`_._-_._��_'__._____ ---------------------- -------------- ______ Distance to nearest: Well------1 ____._..____-Foundation_._-_-��U -��_ _property Line_.:__ ---- . - - . SEEPAGE PIT j ] DepfhIL _... --_. =- Diameter --Number --- r------------- ock .Yes ❑ No :.., ' R Filled i I Water Table Depth •------------------- ------ = .Rock Size ' --------- ----- ` ( ---------------------------Foundation--:------------------- .Prop. Line------- t - Distance to nearest;Well________________ REPAIR/ADDITION Prev, Sanitation Permit#---------------------- --- - --- -- _. -- ------=-------Date----- " - Septic Tank (Specify Requirements)----------- ------- = F -----:- Disposal Field (Specify Requirements).____________-------- ______ ________-f__ r f i :------- -- -------------------------- ----------- ------------------------------------------------------- : .. -------------------- _ _- ----------------- -- -- --------------------------------------------- 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 thepiollawing: -•• g, i "I certify thavin the'"erformonce of'the'woi•k for which'this permit is issued,,IL.shall not em to 'an to become subject-to Workman's Com ensation ..laws of California."- Signed alifornia."_ .. p y Y person in such manner as Signed._-- --� ' ---- -- s ._-.... . . .-- - --- --------------Owner B , Y" -- -. .. f ._ -___ - ---- --- _ _________ _________ ,. . . , T ; ,....,.::.,; itle (If other fithan-o ner} `" ...« FOR DEP USE.ONLY APPLICATION ACCEPTED: BY_;" - DATE. ------------- -DIVISION OF LAND NUMBER _ _ _ __ -- -_ _ 4 --- -- - - -------------- DATE-- ,. ADDITIONAL COMMENTS-.--- ----------:- ------------------------- ------------ -------- - . . -------------- ----- , -- --- - ----- - ----------- ------------- Final Inspection by -------------------------------------.-.--.-------=--------- ------" --- EH rs sa - ------------ ----------------------------- --- Date. 4. e SAN AQUIN LOCAL HEALTH DISTRICT 677 REV. 7176 3M