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FOR OFFICE USE: I FOR OFFICE USE: APPLICATION FOR SANIT� ATION,PERMIT ---- -------- ----- 3� ------------ ---------------- \4v Permit No------- ----'--------- (Complete in Triplicate) --------- ------------------------ -------------------- Date issued S=7 f- _____S ! This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin..Local Health Dis;lrict for a permit.to construct and install the work herein described. This application is made in complia``nce wit unty,,Or_dinanee No. 549 and existing Rules and Regulations_ } w JOB ADDRESS/LOCATION_. ._��{/J. 7. .- ----•- .. ----- ------l�J�---- _'� CENSUS TRACT--------- -_-- ----- Owner's Name-- - - A "'..C_._'. :--4t------Yrs F j ' Phone.?.P— - t 4/ K.!/ �icityi)'YC zip -------- -------------------- 2 4 11176 S Address---�------ ---Ll 1 T 6 -I� ------ry:.. ---- P -- , ��` / Contracto�'s Name---------------- ---- �i:P{� x'�' =License # �h�. Phone Installation will. serve: ; Residence ❑ , Apartment;House E] Commercial E_ Trailer Court ❑ , i`a 1- . . s`' . .;._�"-�-- -•�- ��MotelY❑;tiOth€r'f ---- °--- _ :.. ..--------=- Number of living units:_____f :______Number of bedroom`s :, Garbage Grinder ----Lot Size__: ,o 5uplply: Public System and name ----------- --- `-=----------- ---------------------------- WaterPrivate 1 _L _L � . t: � = .: Y Character of soil.to a depth of 3 feet: ,pSdnd ❑Q�Siit ❑ Clay [I Peat❑ Sandy_Loam � .:Clay Loam Zird an - Adobe Fil! Material_.'.__..._ -ifyes, type_ __,__..___._ � ,gyp �., � ❑ � - - [Plot plan,'showing size of Iot,`location o{system in relation to wells, buildings, etc must be placed on reverse side.) 1 .NEW INSTALLATION: "'.(No,septic tank'.or seepage pit permitted if public sewer is available within 200 feet,) i CJ PACKAGE(TREATMENT [ ] SEPTIC TANK Size_._.___ - - ! - Liquid Depth.__ _______.__.-_- r C L , �Capacitl010._:.- 'TYPe1 _ LCompartments----------- �- ---------,--- - 1 1 Distance to nest: Well-------- --- ------------------Foundation--'----1 -- -------Prop. Line___��-- ----------------- are LEACHING LINE ' A No. of Lines-- ,-- ��------ ------Length of,,.each __-Line_---.-��_f Total Length,:.__l�Q__�______ _ ________ :Type Filter MateripL__J0LT�.__ epth Filter Material______ i�-_-----_-----------------•----•---------- # F `— anceto neWell r Foundation J , • arEat: Well-----�Q-�-----�--- dation --- ---1-�-----t-- - Property Line---��- -- ------------ Distance 'i SEEPAGE PIT ] Depth.__ .___Diameter_;.__,)' /'---.Num - ---r�____,______ Rock Filled Yes No'❑ � . , Water Table Depth---- -------- - ---- -�'n:------fes'--Rock Size--- t 11- ®__ o_ --------- l � .__.Prop. Line____�___ __.___.__Qistariceto nearest:Well_""=_ REPAIR/ADDITION ----------- (Prev. Sanitation Permit#------------=--------- = = —Date ' = ) 1 Septic Tank (Specify Requirements)----- --------- ----------•-------------=---- ------------------( ------------------------ ---=----= T_.' =" � I DisposalField (Specify Requirements)------I--- -----------------------...... -- --= -- = = ----------------------------------------------------- --------------------------------- ------- ------------------------------- ----- - _f- ---------------- -------------------------------------- ------- -------- --- --------------------- ------ r - --------i i(Draw existing and re u red addition onfeverse sde) _ hereby certify-thatI have prepared this applicati n, and thatthework will,be done in-accordance with San Joaquin County Ordinances,; State Laws; and` Mules and RegulaRlons of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "i certify that in the perforrriante of the work for which this permit is issued,J_shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." ---- = ----------------------------------------- Signed 0wn�rxn EY { ------------ ± jTifle ' --------------- -- ---------------- -- - --------------•----- ------} (If other than owrier) r ` .- ---�� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED By...... ,r -- ------.-----DATE------ ---''----- DIVISION OF LANA NUMBER------------------ --= ---- --`-„--- , -- -------------_ a::-------- ------------------ ---------------DATE.-: ---------- ----------=- - ADDITIONAL COMMENTS---------------------__------------------------------ i :. - _ ---------------- = - - ------ --------------- ----------- ---------- ------------------ -------------------------------- -------- ---- -------'---- ------- ----------------------------------- ------ Final Inspection•by:�'- ----- --- ---- -------------=---=}= = ----� � ----------------- ------------- --------. _Date- - -=��- - - ------- --�-"- ----- Fps 21677 Rev. ��6 3M --- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT �`