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�. -APP>1.1CATION FOR SANITATION PERMIT �35/ FOR OFFICE USE: -; ,'�,mtrNo. --"--- - ------- 5Sd-_70 { j (Complete in Triplicate) rro Date Issued ----'------ as a. This Permit Expires l Year From Date Issu 7_a--------- e Application is hereby made to the San Joaquin L6cal-Health District for a permit to construct and install the wank herein -------------- pp lication is made in.compliance with Count-y-Ordinance-No. 549 and existing Rules and Regulations: described. This a pp ie � � CENSUS TRACT ------------ -----•-----.. JOB ADDRESS/LOCATION _ - ' y C' Phare _3.e - - Owner's Name -. 30----- ; - --------------- City ------------------ - Address -------- ---- License,# Phon Contractor's Name -------IR00--- -- !D�% Installation will serve: par Residence tment House❑ Commercial :❑Trailer Court i❑ Motel ❑Other ----------------------------------- -----•. y �7J1��✓-- --- - Lot Size _. -- -- - --_---Garbage Grinder -"__--- --- Private- - ---- -- -- -� Number of living units:_.-" _- Number of bedrooms -" kt!t- - ---------------------- Water ---- - Private ❑ Public System and name --- Water Supply: y -----L-�- -�--- - - Character of soil to a depth of 3 feet: '"Sand'❑ Silt❑ Cloy y Peafi[� k Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material .----- If yes,type on Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must within 200f a#, reverse side.) \s Iavailable NEW INSTALLATION: (No septic tank or seeps pit permitted if public sewer is ize- __ -- Liquid Depth -----1 PACKAGE TREATMENT [ ] SEPTIC TANK " (, /�� t ��rLS - Material .G)^ No• Compartments --.------- i Capacity - - ------- Type 1tQ r ---"--_--•Foundation -- -- -----"-- Prop. Line _�---�----•----- i D' tance to nearest: Well ---------------- 1 j -_--- Length of each line --- - ------ - --- - TotaV Len th J Di of Lines // ! LEACHING LINE [y}�. f --- - ---- ----- - ! l� -----•-----•-----.......... 'D' Box --- Type Filter Material "_ �- pt Filter Material --_-,-- / � Property Line - - Distance to nearest: Well "--"-' ----- Foundation --- ---"- �';- -- _ Rock Filled Yeses No 0 SEEPAGE PIT L p - Diameter -r�------- Number . `�--------- Depth �,T--- ----- � --Rock S' !� - Q ------ Size - - � = --------------- J ' Water Table Depth --.---r— ----------------------- �--`�------._Foundation - ----1��-�--- Prop. Line -"-------------•------ Distance to nearest: Well _--_- ---- REPAIR/ADD1TiON(Prev. Sanitation..ermi ----------------------------------------- ..--..Date ---------------------------------•--k L ) -- ---------------------------- Septic Tank (Specify Requirements ----------------------- - ----- 3 -------------- ---------------------- Disposal Field (Specify Regv;rements -----------.- - _----------------- ------------ --------------------------- ---- ------------- --------------------- Draw existing and re uired ---------- reverse-- - " - - -- " - addition on reverse si e1 ace h Son Joaquin in ac ne I hereby certify that I have prepared this application andstof the San Joaquin kocalat the work will be doHealth Distr'�dCtnFlonsetowner or licen County Ordinances, State Laws, and Rules and Regulation sed agents signature certifies the following: ersan in such manner "I certify that in the performance of the work for which this permit is issued, I shall not employ any p as to become subject to Workman's Compensation laws of California."I y Signed ----- ------------------ ----- -- ------- - ----------------------------------- Owner-- - -------- Title --- CrC --�L -- -- (If other owner) t FOR DEPARTMENT USE ONLY -- �` DATE�I r 2o � " i lj . . --- - -----DATE ----------------------- ------------------- APPLICATION ACCEPTED BY --��- -- ------ ----" - �- - 1 ----------------------------------------------------- BUiLD1NG PERMIT ISSUED ----- ------ ------ ------- ------ - -- - --------------------- ADDITIONAL COMMENTS ---e_ - ----- ------------- �` -------------------------------------------------------- ------------------------------------------ j - -- --- ---� -------- - --------------------- --- - ------ ----- ----Date. -------------------- -------------- - --- --inalIn -tio ------- ------- --- --------- ------ - � r Final Inspection b -- - " SAN JOAQUIN LOCAL HEALTH DISTRICT F- H. 9 1-'6B Rev. 5M