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FOR OFFICE-USE: FOR OFFICE USE: tv r APPLICATION FOR SANITATION PERMIT r (Complete in Triplicate) Permit No____ ________ - ---------------------------------------------------- ---- L,PT `? c, Date Issued----- -------------------- This Permit Expires 1 Year From Date Issued 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 )�� 5 -,._; t� .lii� `' ] ----------- # --- ----.CENSUS TRACT - Owner's -- - -------- - - --- �. , • _ .. _ ------------ ------ -- . ----------: --- --Phone-------------- --------=----- --- Address...._ �' f � � --- ---- City />!r Zip---- ---- - --- Contractor's Name/ ?t �-� } - - �q r- p-� �• ,e„ f License -------Phonel /,f"fn r4_Fr 4tf"/f Installation will serve: Residence Apartment.House,E] Commercial ❑ Trailer Court ❑ ' - . 9 � . -- arba e Grinder__....- -`-Lot Sizet<,4 , Motel ❑'-r-rOtFier.--;----'----_ ------------------ Nu ¢ Number of living units: of bedrooms... __._...- g z Water Supply: Public System and name... . ---..:.- I' ;.: = ----------- ------------- --Private.. Character of soil to a de'th of 3 feet: • Sand ❑ Silt[] Clay ❑ Peat ❑ Sandy Loam El Clay Loom ❑ LL 4 ' w Hardpan ❑ Adobe '-,Fill Material es, � � Y type------ ---`- -- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. mus; be placed on reverse side.) # NEW INSTALLATION:" (No;'septic tarik ;of seepage :pit permitted f. . Capacity..�JrC�_ if public sewer is a vailable within 200 feet,] PACKAGE TREATMENT SEPTIC TANK G�°� ,------------------Lsqu•d Depth_,_J'G&/f = 0 ----------------- ------ ---- - - --- -----TYPe----------- { Material. iNo. Compartments mpartme1n ts-------------------------'------ Distance to nearest: Well.,.._j -e__-_- - ---•*------- _--FoundatiopLine_-.�__f............. LEACHING LINE f�j No, of Lines_ __. ___._ __,Length of each'lis._'- - _____ -__ -Total Len gth..-_,_. __+-____ _ - �k D' $ox-.^�C*';-.Type Filter Material _JYi� ---Depth Filter Material.- �------------------------------------------------- Distance --- 5----- .. 01: - € t ---- ---------- ------- Distance to nearest; Well------C.................. Foundation-.__:__A; -.Property Line...... Q.. r. .f. s . t SEEPAGE PIT [ ] Depth----------------Diameter. -------;------.----Number.--,__-_!_._____:-_____ Rock Filled Yes ❑ No r f s Water Table1Depth Rock Size r------------- ---- ---- - Distdnie.to nearest: Well t ° - -- --- - ----Foundation ------------------- .'_.Prop, Line F REPAIR/ADDITION (Preva-Sanitation Permit*-,------------ _ ' ---------------=--- -------- -Date. _ ------------ Septic -Septic Tank (Specify Requirements)-.--/g!? ,0.-4:0..9.4,---- ( ]' - s = r! is'Posal Field (Specify Re uireme�nts) _ _ CW AA.e-_ - / s, ---- --- H (D'raw existing and required addition on reverse side] i I hereby certify that I have prepared this application and that the work will be done .in accordance.,vrn'th 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: j "1 cern that in the f ! fY performance"'of;the'work for which this permit is,issued, I shall not employ any person in such'-manner as to (becomes ject to. Workman's Compensation .laws of California."} Signed_ . ._�Chivner ; . Y-------- ----------------------- --------------------= : - --- ---------------------- ---------Title. (If other than owner) - --- � 5 FOR DEPAR ENT US ONLY APPLICATION ACCEPTED. BY v _ ._ ---_ DA - .— DIVISION OF LAND NUMBER :...___ ,. -------------------------------_----------------------------- - �- - DATE ADDITIONAL COMMENTS__._- -- --- ----------------------------------- ------------ ---- ------------------ -----------.------ --- -------- ----------------------- 1... ---- ------------------- ------- i k - - ---- --------- ---------------- - --------- ------ - ----- '---------- _ ' -------------- - i---- ----------------- Final-Inspection•by:..._:-�- _Date-- -/su!... "� - - - 4 - EH 13 24 SAN'JOAQUIN LOCAL HEALTH DISTRICT F8s 21677 REV. 7176 3M