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r - .,,F6*R OFFICE USE: E USE: FOR OFFICE APPLICATION FOR SANITATION PERMIT FIC (Complete in Triplicate) Permit No._.. !- ---------------- ---------------------------------------- -_____ This Permit Expires 1 Year From Date Issued 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: JO8 ADDRESS/LOCATION-------_ '..f -, �-�- --- 'W--- c_-N�i ley,{ _I� P CENSUS TRACT-- ----------------------------- RACT ----------------- _.. -- - = Owner's Name------ ---- - 9.�2J-- _� y--------- -- -- Ph — Address_i ------------------ ---- ---- -----City --C-- --------- -------------Zip---= ' Contractor's Name i[--- p..��G._t2.:.-- -----License #-o`J ��:$�_ - _-_Phone. 3 49�'l� � -.. installation will serve: Residence ❑ Apartment House ❑ Commerciatj;y Trailer Court ❑ ----.-i, d Motel ❑ Other---: --- a e- Number of living units-------- of,bedrooms-------------Garb age{Gelhcler_.__---_----Lot-Size _. ' __- Supply: Public System and.narrie` _____ ----------------------- Water ------------ --- ----- --- - -------- Chprarivate cteriof soiIJo a depth of 3 feet: Sand ❑ .Silt❑ Clay ❑ Peat 0 Sandy Loam ❑ Clay Loam S' i YR 3j _ a s- 4Fiardpan-❑w Adobe❑ "' Fill Material_.. I yes*..type r.--- ,------ -•--' s 1 t: • ------- (Plot 4 (Plot plant, showing!size tof lot, Location of system in relation to,wells, buildings„etc. must be placed on reverse side.) NEW INSTALLATION: `(No'septic tank •or.seepage pit permitted if public sewer is available within 200.feet,] PACKAGE TREATMENT [•�J-+SEPTIC:TANK—[`l: `Size""` _ ” �y-------------------- Depth--5--------�--._--.'_- I 5 Capaci.'ty --.TYP =_ =;`-'- � WC-,tcr al'-,_V\....------•--------No. Compartments .....� Distance�to-nearest:1Nell ._ --. _-_- Foundat,ian Pro Line___ _ - p• T� LEACHING LINE [ ] No-of Lines------- I----------------, Length of each lino___.� �'4.__. __._...Total' Length. .____- � 7 [ ' —'D' Box}.S1__-__.__Type+ilte'r� aTenal:I Depth Filter Material__-_----,r --------------------------------- -Distance J _ ------____.- Distance to-nearest:�Wel-17 Foundation---- ------- --------Property Line --_------------------------ ' a SEEPAGE_ PIT [ ] Depth.---- -----'--\,Diameter----------------- --.-Number---:------------- ___--- Rock Filled Yes.❑ No ❑ Water TabI' 'Depth � r p Rock Size---------------------------- ( Y Distance.to nearest: Well-._._.__"___:_ Foundation.------------ ------ ---------Prop. Line---------- l REPAIR/ADDITION (Prey:Sanitation Permit#_ _:------------- ---------------------- -,--------------- ] Se 'tic:.F.anlrSpeclfy Requirements)-----:------ ----- -------------------=------------ Disposal Field (Specify Requirements) --------------------- ------------=------------ --------- - '---------------------- --- -- ------- ._,�. - � - - ---a--,------- ;- - -------------- --------------f----- ---.;. �-'VIII >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 Son 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: ± i "I certify thavin the performance of.the work for which this permit is issued,1 shall not employ any person in such manner as to become subje/-tt- Wor man's Compensation laws of California," r Signed__.__' :. -------------------------- - -----=---------- --' -- Title ------- 4 (If other than :owner) .. ._ ,. ! i DEPART NT USE ONLY; APPLICATION ACCEPTED BY --- ---- -- ---- ------------- DATE DIVISION OF LAND NUMBER---------------- -------------------- DATE-- --_----------- ' = ; '. ADDITIONAL COMMENTS---- °- # ----------------------------------------------------- --- ------------=---- a ---------- -------------------------------- ------=-----------`--------------------- ------- ---------- ------------- -------- - - - = _ - - ---------- - - Final Inspection bY=--=----- ---- - Date.------------ EH t sH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M