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' #FOR OFFICE USE: � FOR OFFICE USE: ---- APPLICATION T-OR SANITATION PERMIT (Complete in Triplicate) k i iPermit ------------ No.... - - ------ t: This Permit Expires1-Year From Date issued` -�- Date issued_-1�-- �� r � 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._=.,_. /Y --....... -------/ %Y�cy - CEN Owner's Name-:--- �U tiu r ... = - __ _ .. _ _:.. - - ---•-•-•---------------- -------------- -- - ane Address. = 7; '/yot�J� 4�- woe, ._ Ph } City-_�r�._. :. - dip Contractor's Name - _r- YT P...... ....... JcaN~ T /�6:`K 5 }-/. / M License #_..---- ---------- ----Phone--- --- . Installation will serve: Residence ❑ Apartment House.0 Commercial ❑ Trailer Court ❑ , t. �4• Motel ❑ Other__. . cq:6./`. . J�/o.r►� f.. Number of*living units:•....__1._.____Number of..bedrooms ____Garbdge Grinder---------- .Lof Size,_ ? i Water Supply: Public System and name.._..r_.. - ;- ` I_ - Private , Character of soil to a depth of 3 feet: ; Sand E] ;Silt E] Clay E] _ Peat Sandy Loam !Clay Loam ElA Hardpan E] : Adobe�❑` Fill Material------------if yes,type................•'-__' r.---- (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 taril"or seepage pit permitted if public sewer is'available within 200 feet,) L PACKAGE TREATMENT--[ ] SEPTIC TANK ]`] r Size:__.::.: :-f- o J, --------------- ------- - ----=------------Liquid Depth..------•------ F Capacity_ �Z46 _Type-�'r� Cia5:7 ' - ater(a _:--- .vw�-`- --__-No. Com artments-_-_�= ...'Dista_nce'to nearest: Well__.._ 00:•`• i n p - _..__- : F s ---Foundatio �.�__r.... . ---Prop., ---/Sa"'� LEACHING LINE; [:] � � O , s _ No. of LinBs Line _:_,Len th of-each line...,:-----,---- --------------_Total: Length . ------------ -------------- qa, 'D' Box_.�--:l-_:.°._Type Filter I - - .. . _, Material:-ial:__?O`�r-__-Depth Filter Material--.--A --------------- ,. ---------- t `a N Distdncltoneost: Well - 3"av .............Foundation -- --- --- ----PropertyLine..l401f ., . : -SEEPAGE PT Depth- - Diameter m .. i RocF11led Y_.-Nuber•--------- ----------------- C91J ' Water Tdb :.Depth--- -------'.---Rock Size---- _> .'�.L. ---------------------------- �'Distance to.nearest. Well_z,__-- ------ --•- ----- - ---- ---' Foundation"i----- "----- -__-_ _.Prop, Line.--•--------_-__-- __ . REPAIRfADDITION (Prey Sanitation;Permit#_:_. s.::'----- Date..........:.: - - Septic Tank (Specify,Requirenlents):-i_.._ _s___.__:. ......) ..__....___6------------------------_________ t _____________________________.-- Disposal Field (Specify Requirements);____.._...-_'_.__- --A___--___-__,_____- ------ ---------------------------------- ------------------------- - --•---------•-------- ,l I - 1 �.___._._.--_' ________ ________________ _________--_ _ _ ' e . -t - _ -- ----- ... __ I (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 licensed agents signature certifies,the following: 1 "1 certify that in the performance'of the work for which thispermit is issued, I shall not employ any person in such-manner#as to 'beco �� ... [V _ _ Signed :me 'subjectt�Wo�Workman's. �m-So tion; laws .of Cafifornic. i . / p .......... Owner i. .�. . - --- -- ---- -- - --------- ---- -----• --'-- ---�.. ----- --- Title_..------------------- ----------- ------------ ------ ---- --- ---- { er than owner) �^ 'FOR'DEPARTMIWT USE ONLY, - L- -•- .4• APPLICATION ACCEPTED BY_._.._. ................ ... .. -------------------------- DATE...DIV ISION OF LAND NUMBER-.., - --_---DATE.:...------. -- ADDITIONAL COMMENTS._._-_..-..:.._,-.-. -- --.•-- j:• ------- l ...--- -- - . . t - --- _-------• ---- - ----- •--• ------------ ----------------------------------------------------------------------... ._-- Finpf Inspection by:------- - - Date..... ._" EH 13 24 � �.... -.�- —---- SAN JOAQUIN LOCAL HEALTH DISTRICT ` FSS 21677 REV. 7176 3M .