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I FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: I (Complete in Triplicate) Permit No�T?----- 1.-- i ",----- This Permit Expires 1 Year From Date Issued Date lssued`S'�-ark g- Application is hereby made to.the Sari Joaquin Local Health District fora permit to construct and instal! thework herein described. i This application is made in compfionce with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION........- �z ---- ---------------- --� � - -- -..... - - -.---------------------------------CENSUS TRACT.-------- Owner's Name •-�---�- ---.... ..- ,.... Y . e:.T._......_ /�- }` .---.... .--- :. .... ..............Phone Address-._. Tery� .9� J3 _ ----- City-_ L�sc,s*¢a.✓ I i p Contractor's Name........ -----. 1 License #_!66_' SF Phone:? ° t -� --�-�� ---�-- -� _ nsta lotion will serve: Residence g Apartment House [] Commercial ❑ Trailer- Court I Motel ❑ Other__... - -3 Number of living units;._.._.-f..--,---Number of bedrooms---:3-_.._Garbage Grinder------.--.--Lot Size-.--��-.�c�'� Water Supply: Public System and name. ..- ----- � .... ----- - - Character of soil to a depth of 3 feet: Sand E] Silt[] Clay E] Peat E] Sandy Loam ❑ Clay Loam .y E Hardpan,❑ Adobe E] Fill type-•-•------Fill Material.. _- � - r � --• --- — -- --.If ------------ -----r (Plot plan, showing sizeof of t location of system, i' 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 - f Ca otic �:--�- � •- .--.... --------- •-`------------ ------------------------Ligvid-Depth--�------ ------- ...._.._. ' 4 ) _ .ZO� .-- -- ype---- '`�Matarial Gam '.: } Size....___. F Nod. Compartments Distance to nearest: Well-- ------------- Foundation...:� ----- Prop. Line---//O ' i LEACHING LINE ( ] No. of Lines ... 3---- y0', w I ----`--------.Length of each line ....... .-=----Total-Length_./ a.. D' Box._.-J__....Type Filter-Material...�a�. -_...Depth_FiEter Material.... .��----- . ---•-------- - -------- < <•.�D[stance:to_nea.rest.,Well-_--..--•---------------- --Foundation_........---...-_......_ .Property Line.---......- --- -- - ------_--- SEEPAGE PIT ] Depth.-"'� ..:_.. -Diameter _. Number..._1-3---------------------- Rock Filled Yes ® No E]Water Table Depth ----------� � ------a- Rock Size:.:Distance to to nearest: Well------ ------Foundation.._ :........... _ ...Prop, Line....�F .`...__ ....... (Prev, Sanitation Permit#..__._._.._...- ----------Date........ r Septic Tank (Specify Requirements)_ ----#.... :.........:.. / ; Disposal Field (Specify Requirements).,...:. ----- - -- ------- � - `---------- -- r q - ---- ----------- --- ,... - 1Drow 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 F signature-certifies the following: "I certify that in the performance of the work for which this permit is issued I shaft not employ p y an y person in such manner as to become subject to Workman's Compensation laws of California." a - Signed.,!. _,4iv7_, h L ... SorV--------------------------- - Owner i ! By..... f .... - Title.... - ` --------- ------------ (If er than owner) 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.-.__ ,_-. -.- ..-_ U " ' - ---------...- ... DATE = DIVISION OF LAND NLIMSER-------------- -. � . ---- ------:_.._.DATE...._.... ........- ADDITiONAL COMMENTS....................... ...... ...... -------------------------------- ---------------- ----------------- .... l - ............ ................---------- ............. .._____._...._._ --..._...._...__.___...._......_=. - ---------- ..-.._.._ _ Final Inspection by:_..._ .+'..- Date. -^-- .... ---------- -- ------ - ` EH 13 24 SAN JOAQ'U LOCAL:HEALTH DISTRICT', ts441677 REV. 7176 3M