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FOR OFFICE USE, ....................................._.........._ APPUCATION FOR SANITATION PQMR Permit No. .�s (Ct nplete in Trlpmente) ... ............................. _._---_--_-._ Tlds Permit 15rptrshs 1 Tow From Datehiwed Date issued Application is hereby made to the San Joaquin local Health District for a permit to condrsid and install rhe work herein described. This application is made In compliar_-• - nni �wn„u y Ordinance No. 549 and existing Rules and Regulations. JOB ADORE A . TI �r ...._. J...�............... .................CENSUS TRA . Owners Name �y ............_. . .......... Atone00 _/;_oj. S1_..--- Address ... j�a'T-. ---_--Cityx _._... r. Contractor s Name _ �. �.... �[.4c•Z00, � __.. ......-----License AQ.2X7/___r9Phone - Installation will serve: Residence�A,pw __ parthrh.nt Flouse Q Corrhrrerdal❑Troller Court fl ' Motel❑Other..........................-......_..... Number of living units:..... _._ Number of bedrooms -3.--Garbage Grinder ........... Lot am .el_' ,/..... . j, Water Supply: Public System and ram -----------_ Private[3 Character of sob to a depth of 3 feet: Sand❑ Silt❑ Cloy ❑ Prat❑ Sandy Loam C3 - Clay Loam❑ Hardpan Q Adobe❑ Fill Moteriai yes,type Mat plan, showing size of lot, location of system in relation to wells, buildings, etc must be placed an reverts skid M&W DWALLATIONr (No septic tank or seepage pit pem.i.`nct if public sewer Is available within,21W feet,) PACKAGE TREATMENT [ J SEPTIC T/WK{) Sia..:...._.:_......_........................... .-.• f Capacity .................. Type _.......... Malerlal...................... No. Compartments .. ..»._....» �# Distance to nearest: 1Ah11 ................... ......_._...Foundation..................._. Prop.Lire.......... LEACHING LINE ( J No. of lines ........................ Length of each fine.................__-.-..._- Totoi Length --------- .._. _ rt,• D' Box ............ Type Filter Material ..........._.......Depth Filter Material .............. ......:.:_ I ` Distance to nearest: Well ....... Foundation ........................ Property LNfe ...r.»_. .. _.... SEEPAGE PIT [ I Depth ........... Diameter ................ Number ............................ Rode Filled Yes ❑ No ❑ WaterTable --------------------_._.—_.._..Rock Size................................ Distance to nearesh Well ..................._.._._»_._... -Foundation Prop. LMe ....... .___.__. t REPAlR1ADDt!S01jill[Prov. Sanitation Permit f.........................._................. Date-----------_-------___.-___--_-) Septic Tank (Specify Requirements) ...............-_-______. __.�.... _._........: ...._....�...__.._---- ---._�_..__...__...._......,... ,. Disposal Field (Specify Requirements) , »-___-__-__---___-__--___. ........................................................................................................_............ (Draw existing and required addition on reverse side) I hereby certify that I have prepared this app'ication and that the work will be done In Isco dawn with See J604WE County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District.Nese owsw or 114911- sod agents signature certifies the following: "1 codify that In the performance of the work for which this permit is issued, 1 sholl not employ any person in suds sewer as to become subject to Workman's Compensation laws of California." +u A Signed . .............•......._......_..._...Owner By. ...... ...._............. 7it1e GE�r-C...................................................... (If other thanpWnerl �k FOR DEPARTMENT USE NLY APPLICATION ACCEPTED BY....................................... `.�.__...-.'.4 1... .. . 44F?.... DATE ....7/y�s.....................: BUILDINGPERMIT ISSUED ......................................... ... ....................... ....._........ ...._......__DATE. ..... ................................. ADDITIONAL COMMENTS.... .. -•-..................................................»................................ ...................._......................................... ..................................... .. .. . •....__.._._....:. .........._. ........ .............._.._....._........... ....__...._........_..._.....___-..r .... ... . ............ .........._ .......... ...- _ .. . ...... ...... ...� .............. 4 Final Inspection by:...................... .... ............. .__.- - .....................DateJ �/....._ F ! 1j 21, 1-6fl Rev. 5�t SAN JOA UIN [GCAL HE DISTRICT 8�7h 3M 'i