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FOR OFFIC: E: 1 / �..3.a._... ............I..... APPLICATION FOR SANITATION PE@��IllT ` ... ................................. (Complete in Triplicc"I Permit No. This Permit Expires Year From Date Issued .... Date Issued .a '•3: 7S Application is hereby made to the Son 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 ...... 0?',33._,... Owner .-.. ,. -'............. CT ...... Owner's Name ....._...._.:._....: � Address .. .. ..._...._....---'....... ...... C. •• . Phone .... •• ....... -------------- city /leZ* Llcense Phone�neContractor's Name .�.,.��••_....... Installation will serve: Residence0 prtment ........ .. .... ..... t Hduse0 Commercial❑Trailer Court Motel ❑Other ........... Number of living units:..-Z..... Number of bedrooms . .....Garbage Grinder/V.-O.. lot Size •-- _3' r Water Supply: Public System and name .-_- - -------. ----------------- -------------------------------- Character of soil to a depth of 3 feet,:, SandPrivateer Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ - Hard an _ . P_ �... _ . ..�. .. _ p ❑ Adobe ' Fill Material _..._..._.._ If es a ..._.._.._. . �`� g : � yes,tYP (Plot plan, showing' size of lot, location of. system in relation to wells, .buildings, etc. must be placed on reverse side.) } ANEW INSTALLATION: {Na septic tank or seepage.pit permitted if public se 4er is available within 200 feet,) '.PACKAGE TREATMENT [ ] SEPTIC TAN Si – ze... e�. � ..... Liquid Liquid Depth Capacity // Q.Q.. Zj�. Materia p ��-..._._.. I. f Type _ No. Compartments Distance to-nearest: Weld; .. F —un d"a -`'--- ' `--. �r .................Fodation ../0._... .. .. Prop. . � W , LEACHING LINE No. of Lines i Length of each line.-----. ......_..._. Total Length W f i g .�. ...__. t D' Box Type Filter Mterial �--•Depth Filter Material Distance to nearest• r r ---•-........... ...... ... i� Well-..:1Z:, -.��._-. Foundation _.. ' r �� i _ 1,4, Property tine ..x�^ a__ PIT Depth _.._ _ . .{.._ Diameter �. . t��...__ Number SEEPAGE •f=:.. ... Rock Filled Water Table Depth . / Yes No [E P � ...............................Rock Size 40 2,1 Distance to nearest: Well ..1-40Z)........................Foundation la.....--..__ Prop. Line _.. — , REPAIR/ADDITION Sanitation Permit# .. (Prev.I ..---•...................... - ---- Date ) Septic Tank (Specify Requirements) _ ___________ ---. -------- Disposal Field (Specify Requirements) ._.._..--- -- i --•---•................................... ••----. .................................• ..... .................:•----•-••-----•.._..__...._.. . ._... (Draw existing and required additG'on revetse side) 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 Rulesesaand-Regulations of tK6 Sdn Joaquin Locat'Heplth"'D'isttict. Homeowner oP lite —n-' agents signature certifies the following: n- "I certify that in the performance of the work for which this permit is issued, i shaihnot employ-any;person in such manner + as to become subject to WYK ' Compensation laws of California." Signed -- •---------- Owner 13y .......... �� ••-f-- - Title ..__ Q/�/ f er tho = = . . [�/ _-.. ..------•.. FOR DEPARTME T USE ONLY, APPLICATION ACCEPTED BY......- 0'1"C DATE -.'z •- - �`.......... BUILDING PERMIT ISSUED `.••,__-• ADDITIONAL ....-_-. - COMMENTS ... r _. .. _ �•-_•- - r .. ....-----•• - ---------- DATE ......................... ........... ......... . Z. �. .---.... ---•-- ._....----•---•---•_........Final inspection by: ---. -•- -- ....... ...... '.._....... ---.....•... .-__........ � . . Date SAN JOAQUIN OCAL HEALTH DISTRICT 3 24�`• E. H.-LI- 68'Rev. 5M -- �'•�– . .. .__ ..