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FOR OFFICE USE: FOR OFFICE APPLICATION 1=0R SANITATION PERMIT C USE: ------------------------- (�� Permit No.__7 --.--/� (Complete in Triplicate) ----- ------------------------------------------------------ -. This Permit Expires 1 Year From Date Issued-----Date Issued , Application is hereby made to the San Joaquin LocalHealth 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: s JOB ADDRESS/L f TION //o� # ------- ---------CENSUS TRACT------------------ Owner's ----`----------Owner's Name- .. r--_�_ . --:-ti--s-p■�-- 4----------. '. -------- --.Phone Address- �-�� . --------------------------- - ---- ------------ ----- ----------- ---- ----------- Contractor's City- zip- -- Contractor's Name -- ---; -------------------- -------------License ----Phone... ` 1 Installation Will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑] Other---------- -----== Number of living units------/_'------Number of bedrooms*__°_Garbage Grinder------------Lot Size_____- -- _-__._________._,._______________________.__ Water Supply: Public System-and,name-i .1----------i----- ------------------ `_-------------------- -- P t ' - -- : rive e Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑. Peat F] Sandy,Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe V Fill Material__.---------if yes, type--------------------------------- (Plot ______________________..___.__(Plot plan, showing size of lot, location of system in relation to wells,-buildings, etc. must be placed on reverse side.) J NEW INSTALLATION: (No septic-tank .or seepage pit permitted if public sewer is available within 200 feet,) N PACKAGE TREATMENT [ ] SEPTIC TANK �a __ f` ----- Capacity-1-4540-0 [ Size ` � - Liquid Depfih----'"�----------- --- ----- Capacity_1_�O 0-----_•�T eP,4_ l�Q. .Material_ :_ .�✓ ' YP: -------No. Compartments------- --------------- ,Distance to nearest: Well--_�_G_ri______________ _______ ___-.Foundation._V40___----------.--Pro . Line__ _____..__.____ . LEACHING LINE. [ Nd, of1ines.:------ ---------------:Length of each line_ ---------.<-��:---.Total Length..--- :-�-�- -.------------------- 5-- � D' Bax-.-/f-..Type Filter Materia! �J!Attk.-Depth Filter Material____/90_____________`-__________--_-------__-__-------_-_. Distance to nearest: Well--14Q---------------Foundation LAO ------- __.Property Line------ _____________. a SEEPAGE PIT [&f" De th._o2.�_{____Diameter._1 -- � � E] ' p. �+� '----Number---------o-- --------- ---- � � Rock Filled Yes ��No Water Table Depth._.: ` Rock Size; GR- - s 'Distance to nearest- Well__,._L_,_ __ ______________ ______Foundation._.. ®.`'..__-___ Prop. Line.-, -.--_-___.___.,_. REPAIR/ADDITION (Prey:Sanitation Permit#_.-_____________ _ __________ fiDate-_____.__ •^^= -•--------- ------ ----- ] . .� Septic Tank (Specify Requirements)----------- ---- -------- --------------'------------------= ------------------- . = Disposal Field (Specify Requirements)----------_------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- r ; -------------------------------------------------- ------------------------------------------------------------------------------- --------------L----------------------- ---------------------- (Draw existing and required addition an reverse side) r. 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 Rules and Regulations of the San 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 is issued, I shall not employ any person in such manner as to become su ect .to Workman'&Workman' Compensation laws of California." Signed.------- 0-114�W lz� _ = e- '-------------Owner By- ------------------------------------- _ s Title_ (If ofher than owner) DEP RTMENT USE ONLY ) APPLICATION ACCEPTED BY ---------- - -- 'w-----------------------------------------DATE -------- ----------------------'---- DIVISION OF LAND NUMBER.--•-------------------------------------- --------------------------------- DATE--.--.-------------------- ADDITIONAL COMMENTS.__ ---_ __ `- �a t 4------!V_z5l:?C ---I.._--��rtw� t?r��j--------------------------------------- ------------------ ------------------------------------- I ------------------- -------- ------- --- n 6 f .` ,~� - - - - - ----------------- ------- - - ----- --------- ----------•--------------------------------------- = Final Ins ection b _ ------------Date.___ EH 13 24AN JOAQUIN LOCAL HEALTH-DISTRICT""-— �� "Fas21677 REV-7176 3M