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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit -------- -------------- - -------------- - ------ --=- •---------------- ---- - ------------- - ------------ This.Permit Date Expires 1 Year From Date Issued :iIssued_/ 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: JOB ADDRESS/LOCATIO i1 Y - - -- CENSUS TRACT----- Ownei:':s Name------- :_-...- ,..• E:— - ------- --------- ---Phone 1r -. £ [ r Address---'--_--_-- ., Co i* { f? { r City �x� 9r_/ ----- - - _ - - --- ------- ---------------------- TA ]'—� �, ntract6r's Name_fz- - ------ p License zip ��^ �i� i . i +r�a�« J�� Phone. 7/Y 9 ____-___ Installation will serve: Residence. a�tment House.❑ Commercial ❑ :Trailer Court ❑ # Motel Other------------------ { t Number of living units:_-`- _f-_-_Number of bedrooms-_ t __Garbage Grinde� Lot Size__-._ Water Supply: Public System and name-___.____.____ .-. _ ` i r 'ri. L �. A- ----------------------Private Ell � Character of soil tt oa dep}th of 3 feet: Sand ❑ Si ❑ Clay ❑ Peat❑ Sandy Loam D Clay Loam'] t i t` '' -€ !lard•an [] Adobe Fill Material- -_-_If yes, D ay t P ti (Plot plan, showing size of lot, location of system in relation to,wells, buildings, etc, must be placed on ruse side.) NEW INSTALLATION: (No septic tank or•seepage pit permitted if public sewer is available within 204 feet,) PACKAGE TREATMENT [ ) SEPTIC TANK �( (_X ---_--------------- r Liquid D pth-=f nf L _ 11 - � Material_._. --------`-----1Vo`. Compartments._- —Capacity-_ /( -AQ type"f�� ~--- ---- E i istance to nearest: Vell-" aoda'io = 1 - - --------- ----------- Iunt _—- ----------------Prop�ra `� LEACHING LINE IVDo•B XLines---T�Iter N4----------- Length off each line.' -/.- -_ Total Length _._`:r------- _----_ 1 r .. . . ...._ �. yP a eriaL ----Depth Filter Material _-/_ l� : Distancetto nearest: ... � s .• .v..,.. .�• ..- M: .. ;. Well_;_{ Foundation____r D k * ! / -__ ----- Property L'mF-= ----- - PAGf-Pff Depfh _J �----Deter ! _ /4Numb _ _ ------------------ Rock Filled Yes� WaterTabl 'Depth Rack Size ❑ ? �2 t A. Distarice'.to nearest: Well--- �i' ' - - i ' = Foundation `� Prop. Line l r 1 n --- REPAIR/ADDITION (Prev.,Sanitation Permit#----f=_:_ -------- ----------- -,Date ---------- Septic.Tank (Specify Requirements)------------ i . -------------- f Disposal Field(Specify Requirements)--``= t J - -------- ------------ ----------- r � - -----f--=--•-k----------------------------;..- ----------------=-a---------- ----- -- - -------- ----- .-r- ---------------------------- ------------ ---------------------------------------------- ----- ------------ ----- i'`GDraw existing and required addition:on reverse sid ) e " hereby certify.that I have prepared this application and that the .work will be done in accordaJoaquin -County with San Joa q hr a Ordinances, State Laws; and Rules and Regulations of the Sari 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 isr issued, -I'shall not employ any person in such manner as 1 E to become subject .to Workman's .Compensation laws .of. California," ` Signed '_ --- -- ., . _ _Cn+vner By-;------ - i`- --- ------ Title_ F A (if other than`owner) � � - • °FOR DEPARTMENT USE ONLY t APPLICATION AEC-EPTED-BY= j ATE'sties I'1q- T ."r DA DIVISION OF LAND NUMBER.---- --- - ------------- ----------------- --.----- _-----------: -DATE-------- --; ----- ADDITIONAL COMMENTS ------------ - --.- --------------_----- -------------------- - ------------------ ti -----------•------------------ ------------------------------------ - --------------- --------------------- --------------------------------------------------------------------------- - -------------- 78 % . - - Date_.____: _._ ------------------------------------ _ _ ----------------------- SAN JOAQUIN_ LOCAL HEALTH,DISTRICT - Fas 21677 REV. 7176 3M '