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FOR OFFICE USE: lk/APPL4CATIOsI FOR SANITATION PERMIT FOR OFFICE USE: r--------------------- --------------- p p Permit No. flU - ' (Complete in Triplicate) Date ------------------------------------.--------------.__.__ This Permit Expires 1 Year From Date Issued Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described, This application is made in compliance with County Ordinance Iia. 54Q a>ad e,�cisting Rules and Regulations: ff n}/ JOB ADDRESS/LOCATION............� -v �/'' ----------CENSUS TRACT------------------------------- U Owner's Name -- _, ..nZf _s'_- iG - --------------- -- Phone Address.......... -------- ---------------------- --- ----- ------------------------------------ ---- -city ------------------Zip----- ------------------------ Contractor s -----------------------Contractor's Tfame _ fi r-.. ---------------- ----- --- __ ------------License #©;r6 Sa11____Phone_V_S'S__yr l_.__ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other--------------------------------------------- �} . Number of living units:------!--------Number of bedrooms__-Garbage GriAdw,...,, ,_Lot-Size._______ -------------------------------________--.-.---- Water Supply: Public System and name-------------- -------- ---------------------------------- ------------------ I----------------------- ----------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay E] Peat E] Sandy Loam Clay Loam E-] Hardpan ❑ Adobe ❑ 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,) Q, PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size--.Q'x __X 5---------------------------Liquid Depth _//-_-..-_--.- t Capacity-A - ----------TYpe w e Material--------------------------No. Compartments ---A----------------------- � f Distance to nearest: Well--- -----------------------------Foundation_ fa___-------_----.Prop. Line-----------------------__._. LEACHING LINE [ ] No, of Lines-.---c;Z--------. Length of each line-14:9V-----------------Total Length._. C ------------------------ , � Z Al Q' Bol_.._/____.__Type Filter Material0,/, '.,aC p`_.Depth Filter Material.--./f_ __________ _ _____ ________._-------_--___ r ` Property Line G.j Qistance to nearest: Wei L _ ________________Foundation_ ___ _____-_______.____-- SEEPAGE PIT [ ] Depth --------•A*,.Diameter_.______.--__.---_Number ____________________ f Rock Filled Yes ❑ No ❑ _ r • WaterTable Depth-------------------------------------------------------- Rock Size--- --`---------------------------------------- �' . -" Prop. Line Distance to nedres}:1Ne11�"-�""------'----------------------------Foundation----.--"�';--:-_--_----- . ------------- ------------- REPAIR/ADDITION ]Prey. Sanitation Permit# " ______.__. _,:. —Date--------------------f�. ] Septic Tank: (Specify Requirements) ----------- ---- -------------- --------- ------------------------ ------------------ Q ----------------------------- Disposal Field (Specify Requirements)!--------.2of --------------------------' ------------------- ---yX G ------------ ---------------------------------------- ------------------- ------------------------------ •-.P 1 ------------•-'-------------'*--------------------------------------------------------------------------------------------------------------- [ (Drawexisting-and required addition on reverse side) I hereby certify that I have prepared this application and thatthe work will be done in accordance with San Joaquin County Ordinances, State Laws, and Ruli s�'and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: ;� L- -•--- ,< "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 or man's: Compensation laws of California." ._... . F _.._ Signed •�' Owner By------------------------------ - - ------ - _-Title------------------- l (If other than owner) R DEPARTME T USE ONLY a APPLICATION ACCEPTED BY----- g ---------------------- ----------------------------------- ----DATE` DIVISION OF LAND NUMBER-----------_ --- �------------ ADDITIONAL COMMENTS----------~ ----------- - ----------------------------------------------- --------------------------------------------------------- - e ---------------------------------------- -------- ---- -------------------- Final Inspection by:-------- - - ----------------------------------= ---------- --------- = Date f Z 7-��--------- ------ EH 13 24 SAN J QUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M