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FOR OFFICIUSE: � FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No.7X�&0,9--_ ---------------------------- -V�-------------------- T 2�f � 1 f� Date issusd_f�-:lµ_:�� _______________-_-__---_-------------_-___-____-___._.__ 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: F JOB ADDRESS/LOCATION-=- _� ------- ------•--Lo �----,----_--- t?_T-_ ,- A -- -- CENSUS TRACT Owner's Name--- f` - L 01/0, SSS, Z Z ---------------------- ---- --------------- - ----------- ...------------Phone i Address--- �2 = 1Z KvN`, City- --------------------------- C ity ; Zip - Contractor's Name ` ' - !I RCVS r _ icense y- p -Phone---- n. Installationf will serve: ! Residence Apartment House ❑ Commercial ❑ Trailer Court❑ ! Motel ❑ Other---- ------------- ther ------=- ---- :--------- 1 of lir g -------- y g e �/ �q� 4 y e Grinder Lot Size--- I ! �� 5 Number of.bIdroomsf_,__.__._ _Garbe Water Supply: Public System and name---=------1----- : = - - - -'-------------------------------- -------------------------------------------- --------Private'j� Character of soil to a depth of 3 feet: ' Sand 1 Silt El -.Clay Ll Peat E] Sandy Urn EJ Clay Loam ❑ t Hardpan ❑ s Adobe E}—Fi-1_Mdter-iaf_..----1f-yes-type------------------------±------- (Plot plan, showing size of lot, location of system in relation to'wells,bCuildin s, tc•'must be placed on reverse side.) NEW INSTALLATION-: " '(No`septic tank-.or seepage pit permitted /JE�b i 's� i�va ble within 200 feet,) PACKAGE TREATMENT- [']' SEPTIC•TAN•K ['] Size— -_ �� =-- --_C�-- ;-----Liquid Depth-----L' -------------- -- _ ______ _ t \J t ; Capacity_._1.!��C''�Type.-- � ... Material---C�•-- �� Q. Comportments--------- ----- ---- aJ� ' a '.,,..,.:Distance°to nearest: Well- -- CD4 -.....------___________-----Foundation r �-'__- Prop. Line_.___��___________ LEACHING- LINE [:] No. of Lines- ..::_ - Length-of each lin�_______�0_� Tota!'�L`eri th�r1 2 j u-� � -: -• � ` � l�2 CFS -- - - i- �g - ---------- .D' Box--'-.I_..:__Type Filter Material -Depth Filter Material---------:•-- \ -- - ------------ ----- - --------- _ Distancekto nearest: Well--------------- .Foundation._ ______- _ Propert ne -----__ __ w , t_ Rock Filled Yes ❑s �No SEEPAGE PIT [r]� "� Depth --- `Diclmet`er fit` -- �--Number_____. ' `y1 r t. aWater;Table.Depth; _��^�R `-G' -------- `z - oc 3Siz , i #' R k e _ Distance_to neprest: Well___ ` _--------------t--- ____Fouridation :_ ___!__. Pr p; Line_- REPAIR A© / DITION-(Prev;Sanitat n it ---------------------- -- -i Date------- ---- ------ -=- �+ Y Septic Tank.(5peci.fy`R€ uirements) a= - . .... ... . : ::: .i - - -_ --- --- -------------------- ---- ---- ----- DisposalField (5 ecifY e uirements ) .. ----------------------------------------------------------------------------------- --------- --- -- ----------- • __ (Draw existing and required addition on reverse side) ��` i hereby.certify that 1 have prepared this application and that the .work will be done in accordance with San Joaquin�County} Ordinances, State Laws, and Rules land Regulations of the San Joaquin Local Health District jHome owner or:licensedragents signature certifies the following , 1 i "I certify that in -the performance of the'•work-for which this permit is issued, I shall not employ any p rson in such Liner af9 to become subject to. .Workman's. ICompensation-laws of. .California." 5/1 Signed -- -- - " Owner .. 4 „ BY.......... --------------------------' `-----� ------ - Title - - - (If ofher Than-owner) POR•DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- �- - - ------------------------- DATE----fes--- �Y-.7 DIVISION OF LAND NUMBER-------=------fir- -7 7 - = = ----DATE-=------ = --- : ---- ADDITIONAL COMMENTS = - -------=--------------i------'.--------------- ---_ --- --------------- ----------------------------- ---- ------------- I ------------ -------- __._ --- -'----- -- -----=---=---------`-=--------- ----------- ---------- ---- -----=-- - ----------__ ------- -- --- - - -- ------- ---- --------------------------- :--------•----- --------------------------=-------=------ --- - - -inspection b -. Y ,.�' saw p Y : .- . - -----------------=------- ---- --- ------ Da#e.- ------ ---------------- Final r E" 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ra,s 21677 REV. 71r76 3M - ''may -