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FOR OFFICE USE: "PPLICATION FOR SANITATION PE' 'T / _. .. ...c. (Complete in Triplicate) Permit No. .... _.......................................... iThis Permit Expires 1 Year From Date Issued Date Issued �.'......... ................................. L Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: _ JOB ADDRESS/LOCATION ... 7: ahf 1,....... « : -. ._..... ......................CENSUS TRACT Owner's Name CC,` L_ I D ................................../.......�............................... ...................Phone .................................. _ Address ... . .........�......fs /V..................... Cit .....:`..•!�(}( y.......... .....:................. .............. Contractor's Name .... ..........i. .. . ...........................License # .................... .. Phone ............................. _ ............................... 1 , Installation will serve: Rerr 'lcfencAparfm�nt House Q Cf6mmer`cial ❑Trailer Couht'Q Motel ❑ Other ............................................ Number of living units:.... ...... Number of bedrooms .:��.......Garbage Grinder.' :. Lot Size :.. ......... ^ Water Supply: Public System and name ........................................................._......f........... ..............................Private ' an ❑ Hardpan Adobe ❑ Fill Material ` ❑ Character of soil to a depth of 3 feet: Sand l I-] C]Silt Clay ❑ Peat 5 Clay Loam ndy Loam yes,-:type .... . . ... . .......... .. (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 1 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ( ] SEPTIC TANK{ ]� Size .... liquid Depth 7 � ........... Ccs Capacity . % .......... TypeMaterial..' L1V`t` i. No. Compartments :.......... Distance to nearest: Well ........t°.�r :`..............:t Foundation ..: f.... Prop. Line .................... LEACHING LINE ( ] No. of Linea .......... Length of each Iini....,1...U'..-. 5 :: �jTotal Length ....26:� .......... 'D' Box ,f- .: Type Filter Material Depth FII i Material .:... Distance to nearest: Well . ... :k�!.` bundUtion' Property Line .......:.......... SEEPAGE PIT ( j Depth ..... .............. Diameter ................ Number ............................ Rock Filled Yes ❑ No ❑ Water Table Depth ...........................................::...Rock Size ............................... Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# _s/... ..................................)Date ..................................) SepticTank (Specify Requirements) .................................................................................._......................_............._................ DisposalField (Specify Requirements) ................................................. .'...................................................I........................... ..........a.5 a:a.............................1-._"........................ ' ............................................ _................ ...... ......... ......_.............. Uv%l (Draw existing and required 6dditloil onrse side) i I hereby certify that I have prepared this application and that th 'work`will tis done in accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or liven• sed agents signature certifies the following: "I certify thatte e rmance �work for which this permit is issued I shall not employ an person In such manner Y P }- p r P Y Y Solto become ect t orkm s Com enso on la s of California. Signed ........ .... . ... . ...................�- r� Owner By .-.. .... .............. ................................... ..................... i./...t.Q.'. .. Title .............................................. (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...../...1. .............................. .............................................. DATE ....Ap.:7:/Z................... BUILDING PERMIT ISSUED ................. ....DATE ....................... ADDITIONAL COMMENTS ..........................................................................:.........................._..........................,............. .............. .............. ................ .......... ............. ....................... ............ ... Final Inspection by: . f `i� �y..j.: � � �7 r '� Date '..'1..! .. SAN JOAQUIN LOCAL HEALTH DISTRICT a u 13 24 1_-aa o... au 7179 3 sr