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' :. I//} /- FCR C3F... USES 7 ,, APPLICATION FOR SANITATION PERMIT - ------------------------ `---a " Id I R Permit No: --------- - �!a71c (Complete in Triplicate) 3 e-v -- --- ----------- -----------------------------t-- _ - Qate Issued ------------------------------------ This Permit Expires 1 Year From 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: JOB ADDRESS/LOCATION --- ---- -------- -- - �------------ -----,---------- ,- -.--- -CE T --------------•----.------ CENSUS TRACT 1 one Owners Name --------------- �ER, -- -- - -------------------- --- -- ----- _ City ------------------------------------- -•------ Contractor's Name ------ --- --- - -�---�- ----=-�----------------License # ./moo S//-- --- Phone � 1(-- Y C� Installation will serve: Residence Apartment House^❑ Commercial ❑Trail&Court i❑ Motel ❑Other ----------------------------------------- Number of living units:__"_- --_ Number of bedrooms ---- ___ YY�� l -__Garb ge Grinder ____"-_--:-- Lot Size ---------------C` - -L---------------- I � iE - - - /� Private Water Supply: Public System andrname ------ ----- ----- 1.�YF--' 1�] Character of soil to a depth of 3 feet: Sand'D Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ r Hardpan ❑ Adobe Fill Material'------------ if yes, type N-_=- _--------1:�y---�-- --- (Plot plan, showing size of lot, location of system in relation to•wel[s, Uuild'ings, 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[ ] SEPTIC TANK'[ ] ize____________________'==--------��--- - -- ---- Liquid Depth ---------------------....-- . _ y r. Capacity --- -4'73 ---- Type Material-------- ----------- No. Compartments ----------------•---- `tt Distance.,,to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line --------------- -,tip - =.fr , / ,'� . / i LEACHING LINE [ ] No. of'Lines ------ ---/-�---------- Length of each line-',----,'4:) _-____ Total Length -----___.0.__.__---__-_.. i '13-'Box _----_----_ Type Filter Materia __ ,:_____Depth Filter, Maternal ___//'----_____________________________ �, J Foundation T_._ ----t - Proper Line ------------------------ Distance to nearest: Well ----------_- -------------- w.� y t y I g ' �a - Diameter Number --- -_ -- �_-_---_ Rock Filled Yes No .i❑ SI=EPAGE.'p17� [ 1 � Depth -------- --- ---- - --------- ----:- Y. i Water Table Depth ------------------------------------------------Rock Size ---- --------------------------- iDistance to nearest: Well ----------------------------------------Foundation _-------lq_.---- Prop. Line ____.` ___..._... REPAIR/ADDITION(Prey.5dnitation Permit# ------- ---- ------ ----------- Date ___'____'. --_______.___-__------_) ,s t d 'Septic Tank {Spec,#y Requirements] .. -- -- ----- 'r'-ti Disposal field (Specify Requirements) q`' ------------------- -- --- r'x --------------------------------------------------- { --T -^~'-"'(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 San Joaquin ' County Ordinances, State Laws, and Rules and Regulations of the San Joaquin,Local Health District. Home owner or licen- sed agents signature certifies the following: i "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 subject to Workman's Compensation. laws of California." .�. Signed --- Owner BY ------- .... -- ---- ------ =---- ----------------- - Title (If of er t owner) �} '4. • .sx. ' r' FOR DEPARTMENTIOSIE ONLY'--*' ' APPLICATION ACCEPTED BY1 L� _-------- BUILDING ----------------------------------------- ADDITIONAL PERMIT ISSUED ------------------------ ----------'.'r----------------------------=-------DATE - -----------•----------------------------- ADDITIONAL COMMENTST----------- -- = = ------- -------------------- ------ --------- ----------- --i ----------k,, tk) ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------- -------------------------------------------------------------------- -----r -- ---- - - - - $ .Date ------'_1177 �_ _.. ------- Final Inspection by; --------------------------- W s �kffLQ SANtJOAQUIN LOGAL-HEALTH DISTRICT �E. H. 9 1-'b8 Rev. 5M