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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR—SANITATION PERMIT Permit No. Zf-SqS_ �'-------t (Complete in Triplicate) ----- '- �''r ---•-------------- -- --- Date Issued y - -� d= --------------------- ----- This Permit Expires 1 Year From Date Issued _ r Application is hereby made to the San Joaquinoca ,HealthDistrict.for a permit)o con t uct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: { " [ r------------- -------- - _JOB ADDREO :. .CENSUS TRA CT Phone Owner's Name ------- ` ....... dD �J Gu-7--- ?5i---Phone---- tor" City---------- --------------------------------- AddressZip ---------- -=------------- --- -------------� / ' s — -� Contractor's Name , * License ---Phone--- � Installation will serve:-" Residence portment House.❑ Commercial ❑ Trailer CourtF❑ Motel ❑ Other---------- ---------------- --------- arb.a 6-P, - `'-----__— Number of.living uni#s:----__�-_------Nurrilr of..b o.oms 1� .Gr-Gr ---Lot Size Water Supply: Public System and.narrie_.;-�_ .- _. ._ - l -----------------------Private ❑ Adobe Fill Nlaterpa.l_-.--_-_.Pelf yes, typen .___L dam Loom ❑ Character of soil to a depth of 3lfeet: . Sand ❑ Silt",_ Cly ❑ ❑ Y ❑ i Hardpan ❑ G,1 i O, (Plot plan, showing size of lot, location of system in relation to.wells, buildings,-etc. must be placed on reverse side.) p' a i pit permitted if public sewer is available within 200.feet,) NEW INSTALLATION: jNo septic tank`or seep.--+--*-I-- Si e = _ iGuid`Depth.--- ---------- Capacity. �� PACKAGE TREATMENT [ ] SEPTIC TAN-K—[7'1] = Ca acit _ / ------I Material---------------------------No. Compartments-- ------- ------ p Y:----------- ..... _.TYp?' -,, ,; /! { _Pro Line----------------------- Distance --- to nearest: Well., �r-- Foundation--.-_-__ p. [ ...--.Len f 1 1ti - Total Length LEACHING- LINE [ ] No. of Lines............ gth of each ane.,--__-_ ---_._-_-- __ _- - r - r 'D' Box------- ----Type Filter Material__. - -:-----Depth Filter Material ----------------------------------- ---------------------------- Distance ------:----------------- Distance to nearest:Well-------------------- ' --- Foundation.--- -'-`- ------------ ---.Property Line-------------------------------- -- „ s ' F r ---- --- ---------Number-- __-- R Water Table Depth--- -._-- ------------ ---- Rock Size Distance,to nearest: W611------- --' ---------=-------------Foundation----------------'-----:- Prop. Line ; REPAIR/ADDITION (Preva Sanitation Permit#------------- - -- ;--------_-------------Date___.----_-------------_---.------�- ) IN Septic Tank (Specify Requirements)_ - I Disposal Field (Specify Requirements)----r _--map--------------------------------------------------- `' r"' --------------------------------------------------------------------------------------------- ----- = --------------------- --------------------- r - -----------------------=----- ------------- ---- -- ---------------- - -------------=-- - ----------------------- (Draw existingand're uired addition on reverse side) 1 hereby certify that 1 have prepared this application acid 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 "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." I �a d /_ -JrOwnerSigned - - - Title---- ----------------------------------- ----------- - ----------- ------------- --------- --------BY (If'other than owner[ I FORD ARTMEN7 U . NLY } APPLICATION ACCEPTED BY-------- ----- A;4DATE -t!P.- --?------------------ ------ ------------ DATE --------- --------------------------- DIVISION •---- OF LAND NUMBER------- ---------------------------:---- ------ ---- ---------------- ------ - ADDITIONAL COMMENTS ------------------:-------------------- ------- ----------------- --- ----------------- ----------- ------------ f� �2- P&6 ...►K--5�-c--------------- ------- ------------------------------------- ------------------------------- --------- ---------------- -- ----------------------------- ----------- {--- - ---'-- - - -- ----------- --- - ------- Final Inspection b Date-___-10- -'Zi- - ------ ----- --------------- EH 13 24 SAN JOAQU.IN LOCAL HEALTH DISTRICT Fes seen REV. 7176 3M L