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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT L --------------------------------- Permit No--- 3 (Complete in Triplicate) f -------- 41.1_0 a_ -- 7-7Date 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 inGo Ii nce with County Ordinance No. 549 and existing Rules and Regulations: ` SSD() t1 . J7)hr.JS0r.1 - �j1 �01r\) (C�3- (?0-CJr 1 JOB ADDRESS/LOCA I,4,,,,_ , l __ --.--- 4 9 .1__ � _ __ __._.._—CENSU..S..TRACT .�.--.----!----------- 747 Owner's Name.-------- �� ...... a'` / ASL ------------ ----- ----------- ----------------------------- Phone--- a P Address-------------- 6A_14,e*_-------;------ ------ ------- -----------------------...--------- Cit -_-Zip Contractor's Name -„Z.--.Au��----------------------------------- _License # "'bSo ___Phone_ _`)''-�� __._. Installation will serve: Residence ❑ Apartment House.❑ Commercial ❑ Trailer Court ❑ s t ----------I Number of living units:------j--------Number off bedrooms Other------------------ Grinder------------Lot Size---- �_____________ i _.__-___....--._. Water Supply: Public System and name---------------------------------- - ---------------------- ------- ---------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam I Hardpan ❑ Adobe ❑ Fill Material______._..-Jf yes, type-..--- --------------------_ e4 (Plot plan, showing size of lot, location of system in relation to wells, buildings-etc..iriust be-placed on reverse side.) � G NEW INSTALLATION: (No septic tank a'r'seepage rn�i'� plit pdrted ifjpubl'kc sewer Ps avdllal;l within 200 feetr,} ] PACKAGE TREATMENT [ ] SEPTIC TANK'- ]�"L”` �; " SizeY__=-_ ..... - - Liquid Depth-W • --------- Capacity---------------------TYPe ---------------------.Material-- --:-- --------;:--;-NNi�'"Cor grtments C , Distance to nearest: Well-----------------_---.._--_-_------- - f .-----Prop. Line------ - ------------------ - LEACHING LINE [ ] No. of Lines----- -- r^_.__--. Length of each lino______moi,�:._...... -.-.--.fiotal Length ---__----_---____________ Z ' .ti 'D' Box-.__.---____Ty�pe�ilteriMaterial,..�..________Dep.th.Fl. er.Material -------------- C, Distance to nearest: Well ___.__.___. ......._Foundatip0___ __ __„t.Frope�Line::,_.._ . " ; SEEPAGE PIT [ ] Depth.---------------Diameter------?_;,____a----Number-------- -------- r Rock Filled YeIs ❑ No [ Water Table Depth----------------- ---------=---------------------- .Rock Size , - Distance to nearest: Well------------------------------------------- o"F unUation.___..__----------------..Prop. Line-------------------- REPAIR/ADDITION (Prev. Sanitation Permit#------------------------------------------ _, _-_ -.--__--------------- --- _,..Date,,,.,,:.; ,,, ------------------------ Septic Tank (Specify Requirements)-------------------------------- ^' = ' _ ------ ----------------------- --------r----------- �/�'ST c A � Disposal Field (Specify Requirements)/ � E >-------=---------- -------------------------------- ------------------------� :!5 -e"q------X114✓ ------------------------------------------------------------ ----------------------------------- ---------------------------- ------------- ------ --------------------------------•------------------_------------ ---------- ----- ---------------------------------- -- ------------ ----- (Draw 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 with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licensed agents signature certifies the following: } "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Wor an's Compensation laws of California." Signed------ . 1tip r �..� ------------ - ---------Owner By---------------------------- ----- -------------------------------------------------Title --- --- ---- ---------- ------------------ t ----------- - ----------- (If other than owner) ; FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . ---------------------------------------------------- -------------------DATE. r%_' =--7 '- ' DIVISION OF LAND NUMBER ._ _ _. . _ -------..DATE- - ----- r - _ ------ ADDI IONAL COMMENTS_.. -�-�. -- -- " ---------------- ------------- ---------------------------- - -------- '-�------- ---- ---- ---------------Q--'}------ - --- --------- --------------- -- ---------------------------- � a --------------------------------------- - --- - ------------------------------------------------------------------------------------------------------------------------------------ -7__ --------------------- Final Inspection by.--- = ---�- - --� -------------------------------------------------------- Date �o---Z-S'--._ ------------------------ ---------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. 7176 inn