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�w F Z)FFICE USE: " _" +,� -1 � _ PLICATION FOR SANITATION PERti,.- -�:--�� ' --------------------------- • -• -•---- -----------•---- Permit No. --- -----71--- (Complete in Triplicate) MAR 1 5 2004 This Permit Expires i Year From Date issued Date Issued .__ ,./3~ 73 ._._. ---- ENVIRONMENT HEAL.I H Application is hereby made to the San Joaquin Local Health.District for a permit to corfsWNGa IWIGHSthe work herein described. This application is made in compliance with County Ordina ye leo. 549 nd existing Rules and Regulations: JOB ADDRESS/LOCATION .1-.%1 --L, ...- - - -- / f,C ....... ___ --- j P _ /�// h- ._CENSUS TRACT `. .... Owner's Name f 'u �'.✓L9' C�' 1f•------------------------------------------ .........Phone ------------------------------------ ------------------ ----_--_------------- Address -- s� L�..:..---------------1................................................. City _( /,��.+�} ,�� Contractor's Name ----- � -= l'L f �_--•--------------------------------License # �/f r�r :_P o •--•............ .. .... Installation will serve: Residence [-]Apartment House-❑ Commercial❑Trar QX;* 9' Motel ❑Other ----------------------------------------•--- Number of living units:.--/..... Number of bedrooms ________Garbage Grinder _/��__ Lot Size L d€ia l st - ------------- ---- .--------Private Water Supply: Public System and name ---------------------------------------------------------_-------- ---------------:••---------• X Character of soil to a depth of 3 feet: Sand'E] ;Silt❑ Clay ❑ _ Peat❑ Sandy Loam ❑ Clay Loam:❑ -I-��/Hard pan X Adobe C] Fill Material ------------ If yes,type -------_--------------_-- (Plot ----- ------------_--(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,) ^ r le PACKAGE TREATMENT SEPT! ANK Size-._ _ 17 -��-s��--~---------------------- Liquid Depth _Irr---l ------------• Ca acit XT e 0 �. p �(�A_-- _ Ty ��`� -- Material.e1,P_`/%�.�_-!_. No. ✓Qmpartments .2�------------- distance eorest: Well .........��--------------Foundation __v __-______ Prop. Line ...................... LEACHING LINE ru No. of Lines -- s a •- :----- Length of each line ��'--------------- Tota[ Length /l`h_____•---•-•__-- D' Box ��- Type Filter Material � d Depth Filter Material � ---_.---______t______`_......_._. Tn .� Distance to nearest: Weli -------- Foundation -------- Property Line ---__-_-______•_ SEEPAGE PIT X Depth -------- Diameter _ ____ Number .....A!7---------------- Rock Filled Yes ' No c Water Table Depth ........ -7------------------------_---- Rock Size ----------- _ d Distance to nearest: Well __ _______________________Foundation --�L��_._. Prop. ------------ REPAIR/ADDITION ---+REPAIR/ADDITION(Prev. Sanitation Permit# _.__....-•----•.-----.-•.................... Date ---.------------------------------I Septic 'tank (Specify Requirements) ---•-------------------------••-•------------•--•----•-•-•-----•------ -------------------_-_--•----- Disposal Field (Specify Requirements) -------------•--------------•-------------- ------- ---------.....------------------....._..--•-------------------------------------- - ----- -- -----------------••------•- -- -----•• --- -------I-------------------------- (Draw ----------------. ---•--.(Draw 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 licen- sed agents signature certifies the following: "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 Workman's Compensation laws of California." Signed ------------------- ------ ------- ------•------••--•--------- Owner By .... ------ .. B Title _. .. . - ..... 9^ (If othe an owned FOR DirPARTENT USE ONLY APPLICATIC$N ACCEPTED BY .... . ........ DATE . `..- ' BUILDING PERMIT ISSUED ------------------------- ---------------------------------------DATE ----------------------------- ------------- ADDITIONAL COMMENTS ---- ---- Final inspection by: - � '�`L�C��' Date ------- ----------------` SAN JOAQUW LOCAL HEALTH DISTRICT F. H. 9 1-'AR RPV 15M