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FOR OFFICE"USE: }v// APPLICATION FOR SANITATION PERMIT LDate R OFFICE USE: --------------------------------------------------------- qq (Complete in Triplicate) No.._7_/:_1�.g This Permit Expires 1 Year From Date Issued ssued.,�,7 f - Application is hereby made to the SanJoaquinLocal 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.___. � 1 u! � � r - � k = - _- - _=.__.CEN5US TRACT--------------- ----- Owner's Name-', .a �` r! -- --- ------- - Address --- -- - -ice? -- „��?Yjly� _% :. -- L� � .- Pone. .City , _ __ zip- --Contractor s Name 1r'. �� , . = - ---- j... i License # ._' _ Phone. Installation will serve: Residence j f ” * ` tel ❑ rt Otheraa ❑ om'i�Fercial ❑ Trailer Court ) ; Water Supply: units:.__ '_____ Number of bedrooms } 'Garbo a Grindex.._` __ `" Number I living f _ g Lot Size__ / - - ------- .nome------- ------------------------- P =-----------------------------�-----_ _ - Character of soil•to a depth of 3 f6et: Private PLO lic System and eet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy.Loam ❑ -Clay, Loam ' Hard an ❑ .' M p ❑' Adobe Fill Material'-. ---------If es, e � Y type ----------- (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 f' ' = 4 pit permitted •ifpublic'sewer is avaipble;within 20o feet,) PACKAGE TREATMENT '[ ) } SEPTIC .. = . TANK i� Size'b�-- K /f Li------- ---- _ qui d Depth -- ---Ca acitY- ---=IType/P Materia -No. Compartments____- (1 Distance,to.nearest: Well.-_ '�: - r`T :. .__._Foundation-- , d ` 'E Prop.. Line----------------------------- LINE ----- `•„ - Ci LINELEACHING No. ofLines_ , --- �-,----.Length. ling 4 � -- Lei th_---_-_ - AX� 1 = --D' Box-./----- -.Type FilterMateric / rth Filter Material_______ o :Distance to nearest. Welly _ll7?' _ ' ._ oundation _� _-- .__,Pro ert Li'ne._. a ��e SEEPAGE PIT ... f e P R t [! l Depth.- -- --------Diameter---- ----4-- ----Numb r__':------- ------ ock Filled �.: t - ; . EJ Water Table.Depth- _. .. - --------------------- Rb& Size: --------------------------- a N R Yes ❑ Distnce.to nearest: Well_ S - ---- ------:----- ------Foundation---------' Prop. Line---------------------- F--- REPAIR/ADDITION (Prev; Sanitation Permit#- : = ' = bate-------•-------- --- --SepLic Tank (Specify Requirements)_-_:_�.-:-_-`- ._ ►, ', y} ' v:DisPoral Field (Specify Requirements) ..,_ .___ .... s ------------------ ---------------------------------- ---------------- ------------------------------ e = ' -- -- --- _ - -- ----- -- p ---- / " - �i ------ -------- i S (Draw existing'{arid required addition-on reverse side) I hereby certify that I have prepared this application.;and that the will done•in- accordance with San Joaquin Ordinances, State Laws, and Rules 'and Regulations of; the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following.*' "•'" `` j y...i "I certify that in .the perFoimance of.the work for which this permit iso issued, I shall not'em loy an- erson in such { to become subject t rkman' ompensation lawsiof .California." � � y p ch manner as Signed----- - - - ' e --- -----------=- -- ' .. ! - -. caner a .r BY- ----- j = _ - - Title E_ _ € . . . - - +i a (If other than owner} •---'.. :. ..sem _ - ------------------------- 0 -- ---- # FORDEPARTMENT E ONLY APPLICATION ACCEPTED BY. Y_ _ ' --- --------- DA' TE ` --- - `} ISION OF LAND NUMBI RF"------------- ---------- ---'.._ `'`- ADDITIONAL COMMENTS-------- 7DATE - --------------- ; J - - - - ---- -------- t - . -- = _ ., - --- -�----- .. _ Final Inspection. -------------- r'. L ) on'b '""" ------------------------------ - .