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FOR OFFICE USE: f#D APPLICATION FOR FOR OFFICE USE- (Complete SANITATION PERMIT (Complete in Triplicate) Permit No.11,79:_J; J_3 t --------- ------- This Permit Expires 1 Year From Date Issued Date I ssue&/r a_/E;_-.,8 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. f This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations; JOB ADDRESS/LOCATION...... - --- oE�4f Com- ' Owner's Name CEN TR - ---------- CENSUS ACT ------ Owner's Name i - - ---------- --- ---- --- op ------------------------- ----- ------- --------- Phone. Address------- ------------- - one - - .Ph -- _ I----- ------------- City- Contractor's Name--- v ' - Zip �6- So .c.Q ---------- -- �s - License # - .-Phone Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ i Motel ❑ Others------------ ------ Number of.living units---"----1 ` _____Number of,bedrooms__-'Garbage Grinder_._�____:_Lot Size_"___" :_ ' s --------- ater Supply: Public System and name----------------- - --_- --- - ---------------- Character of soil to a depth of 3 feet: Sand Siit .Cla � � ivate,❑ ❑ ❑ y ❑ Peat❑ Sandy Loam ❑ -Clay Loam ❑ s - # Hardpan -' AdobeFill Material-.._.:__ If yes, t (Plot plan, showing size of lot, locati n`of.system 6n relation to'wells;�%buidding ?etc. must be placed on reverse side.) y NEW INSTALLATION: = (No septic tank -or seepage pit 'permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT [ ] } SEPTIC TAN eIr K [-I Sizer = x'S ---------------------Liquid Depth---- ---------- Capacity-.- 6P. :Type- Material _-" - -_-- No. Compartments------- C11 Distance to nearest: Welh._:_' f --- ------ Foundation-•----- `�.�f Prop. Line_ �' ..-:--------------- LEACHING LINE No. of Lines.--- _ q. h line _--- = i YP Length �f eac �� , Total Length i D' Box_ __-__.__-Type Filter Material- _ r Depth Filter Material.-__---- -"-_.-"___" " Distance-to nearest: Well": _f-.------:--_p Property Line--- ----__ SEEPAGE PIT r = _ - ro --- --- -- Depth_ � ro :Daarmeter."- �-..----Number_ --- --l. i Rock" �( >�Rock Filled Yes No Water Table Depth._.-,--------------------------------------- Size- r Distance to nearest: Well:_-=-t '- �a t IA------------------------ ,- --- - _- -----Foundation- - 9-` _. l , prop. Line.��-------�--- , v. Sanitation Prt#REFAIR/ADDITION (Prem _-_--_- Date==----- - -- Septic Tank (Specify Requirements)-----.-- _ a :- Disposal Field (Specify-Requirements)--=--------------- - -- ' , i ------------ -------------------------------- ------- --------------------------------- `� _ ; --------------- --------------- - --- (Draw existing and requ1red 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 Coun Ordinances, State Laws, and Rules.and Regulations of the: Sari Joaquin Local Health District, Home owner or licensed agent signature certifies the following: "I certify that in the performance of'the work for which'thispermit is'issued, I shall not employ any person in such manner as to become subject to ,Workman's Compensation laws-of California." _ Signed------------- --------- - ti ri.: A --- - ---- - - - _ Owner --- --:---- itle------------- ~ other than:owner) - --------- Al FO DEPAR ME T IJAE ONLY APPLICATION ACCEPTED BY_ -- ` ; _ lam" ---- -----------------------------=------= -DATE 1-�f� -7- - DIVISI V OF LAND NUMBER--------------_ _""--- - --- -- - ------- - ................- ---------: ----------- DATE---- - ---ADDITI NAL COMMENTS-------- --------- ----------- -- ' -------------- ---------------------------------•------------------------- -- ------------------- t---------- ------------------------------------------------- ---------- ---------------- ------- -- ---- --- --- �' Final Ins ectipn b P Y:-.. �-.--�"- --- -��'-- --------- --..._...�....`- `.+.�.�; k _ --=Date -^�--�- ------------ ---- - - ----- EH 1324 - � �- - SA JOAQUIN LOCAL HEALTH DISTRICT F 21677 REV. 7/745 3M '