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FOR OFFICE USX. FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------- ---------------9>--- �- {Complete in Triplicate) Permit No_______j7-ya ___________ ------------------ -------------------------------------- �/S �7 --...... This Permit Expires 1 Year From Date Issued Date issued..//-__-_.~_...- Application is hereby made to the San Joaquin Local Healths�Distria..for a permit to co•nst4`ct nd, install:the work herein described. This application is made in compliance with County Ordinance No�549'and_,existing-kules and`Regulations: ; JOB ADDRESS/LOCATION.--- ---- ------------- ---- --------- _ _ '-- -__--._:_:_._.CENSUS TRACT...__-.-__ Owner's Name r ` 5-� Phone-------------- Address--- =- : / CitY------ = Zip---:----- ----------------- -- - Ct. . ....... License #_ _ -_ _ Phone Contractor s Name___ _61-8, ` ��j/ (� Q�07 Installation will serve: Residence ❑ Apartment House El Comme cial ❑ Trailer Court ❑ ` t, Motel ❑ Other--= :------------ _------ g - - _ 'T - g - - }---- f bedrooms Garber. e;Grinder,___ Lot'Size._ Wert Nu'-mber Supply; living Public stem 'Number '-- 9� - pp Y Yname---.-) _. --------------------------a --- ----Private ❑ E] . ❑ Y❑ ` Peat ❑ Sandy Lo ay = and .. _.-- Character of soil #o a depth of 3 feet: ' Sand Silt Clay am-❑ Clay Loam Hardpan❑ Ad'obe ❑ ` Fiil Material_ -y -_.If yes, typ.f----------- (Plot plan, showing size of lot, location of system in relation to wells, buildings`, etc.'must be!"placed on reverse side.) i NEW INSTALLATION: (No`septic tank or seepage _pit permitted if public sewer is - , . /i +.►t'1�. avaF ila!{b_:l'e-: w-yith rf 00 fee SEPTIC TANK LiDept h._PACKAGE TREATMENT t Size } q atments----- Capacity::- �TYPe__ Com p rM , lO --- --- -•-:_-,Foundation...)_.- � Distance to nearest: Well"� -- -- rop. Lin ---------------------- ----- LEACHING LINE. "'`- '[•` � � � Line [ .l _ No. of.Lines----_.---- Len th_of each line.=- -.- ' 5 �"�- 4 Total Length `jr� D' Box.... .Type Filter Materia - _ Depth Filter MateriaL_._------ -- ---------------------------- ------- ----- T_ ----- ___' _ undation y LineDistance to nearest: We ------------ SEEPAGE .PIT [ ] Depth_-_ _ ------D.iameter_ mber_.---- _ _____________ Y ! Rock Filled Yes No�❑ i. f s Water Table'De _:_ Rock Size � r�' ---=---------------- -- D i sta 6ce -Aistance to nearest:Well -'----- ------ -------- ---,Foundation --.'- '-.......Prop. Line------------------------- REPAIR/ADDITION (Prev.-Sanitation Permit#._1------- _--_`----------------':__:___ Da#e-----"M: _------'--- -l_- Septic Tank (Specify Requirements)--------------------:.--:.: = _ _ -- ==_ .. Disposal Field(Specify.Requirements)=---------------------- ---- ,------------- L --------------------- --------------------- = ' -----`--- ------------------- : __ ---- i ------------------ ----------------------------- (Draw existing and required addition on ri:verse side) I hereby certify that I have prepared this application and that the-.work will be done-in s__a`ccordance,with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District"'Home owner or licensed age Ys signature certifies the following: r` y *�5 ,gr .- "I certify that in the performance'of'the work for which this ,perm is issued I shall 'not'em to an 'ner P , , p y y person in such manneras to become subiect to Workman's Compensation, laws of California." - Signed i - - 3 wner BY _ ke', -- ----- ----- ---- ------------ -- ------ ------------ - .. .------ -- itleIf otthan owner) , .._ . ... FOR'DEPARTMENT USE ONLY; ,.. - a APPLICATION ACCEPTED BY.- - - ---`- ----------------------DATE.W; eT-27 DIVISION OF , -LA�ND NUMBER' !-�_--- --.� -- - DATE . � - ADDITI AL OMMENTS__l� l .------_- : = i ------ �, o ------------------ ---- w Final Inspection by ---------- -_. __. ---- ----------- --------------- -----------=-- -------- te------14 17,77--- --- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 21677 REV. 7ne 3M