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v .F cd qP - FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------- ---------------------------------------- (Complete in Triplicate) t Permit No. ----------------- ------------------------------------ t -------------------------------------------------- -- This Permit Expires 1 Year From Date Issued €€ Date Issued Fy . Application is hereby made tb the an Joaquin Local Health District for a permit?Tfo construct a1'n install ;the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and;Regulations. # 1 trn/ 1. JOB ADDRESS/LOCATION ._}91705"__-_�__�Fk 049D-WR1t.D__-_ 11---------------CENSUS TRACT �`-V_________ Owner's Name -1=-_PH Mfi?.Q_.��.�.-:: -------Phone ------- F' ---•-•------- Address -------------=-f-_7_0_S-7-----�------ VVV0_f>_M_R1)----------. City; ------------ Contractor's Name --- - --- IV � ----S 1C----- \ftC _.License # --------------------------- Phone -- --------------------------• t•;. r �� IF Installation will serve: V Residence �partment House-❑.Commercial❑Trailer,Court 'EJ , Motel EfOtKer --------------------- - ----,-------- /� Number of living units:----J_� Number of bedrooms�_____Garbage GrinderXES-_ Lot Size:/'t_cRan/6-3Z-_____________ ); - ^' Private Supply: Y I - - -- --:------ It - � ------------------- Water Su 1 Public S stem;and name _ _ ___ _.Character of soil to a depth of 3.feet: _Sand;❑i _.Silt❑,_..0{ay..❑ij�l at_ Sandy-.Loam.�Clay Loam.;❑ t Hardpan { P ..: p ❑fF Adobe-E] Fill Material �_Rlf yes, type _'_ _____-_- ' (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seep a pit permitted if public sDwer is ava joble. 91 within 200 feet,) PACKAGE TREATMENT [ SEPTIC]ANK' SizeFO._� ____X__:_5 __ -------- Li..uid Depth ---��___________._.__. Capacity � ------ i � _ TypehR.15-C-A_-+AT^Material.Cg9ff<-: .-- No:�Compartments -----2---- --._ Distance to nearest: Wel! -------J_l1 _____________Foundation _ -- ------ ____ Prop. Line F LEACHING LINE Plf""No, of Lines-11;133 gth of each line-. __7e_(_ --------- ----- Len ------------ Total Length :----��± -•-•-----' D' Box _�'�-'"Type Fil er Material _- ��-_Depth Filter Material _______��_____________________________ i�'s i 1 Z r3 ;: Q ZZs. �' f ; Distance to nearest: WeIR _ -"fi-----_ Foundation ! _ ` ` _____,_..Property Line ._ '"" ^-..__. SEEPAGE PIT [ ] Depth ____________________ Diameter ________________ Number' --------------------------- Rock Filled Yes ❑ No C Water Table Depth ---------------------------------------=---•----Rock Size ----------- Distance ---------Distance to nearest: Well ________________________________,____Foundation __-___--__��---- Prop. Line _._______-______-____- 1 I REPAIR/ADDITION(Prev. Sanitation Permit# ________.____________________-------_---- Date _________________________________) SepticTank (Specify Requirements) -------- -----------------------------------------------------------------------------:"x---- -•----------------•`--------------------------- ' Disposal Field (Specify Requirements) _---___ y 7 { J ti, -----------------------------------------------------==------ � _ ---------------------------------- ----------------------------------------------- -- .; (Draw existing an''d required addition on reverse side} I hereby certify that I have prepared this application cihcl lthat the work will be donekin accordance with'SaimA I'oaquin County Ordinances, State-Laws, and Rules and-Regulations of the San Joaquin Local Health District. Homeowner or Iicen- sed agents signature certifies the Following: "I certify tb—al in the p orm of the work for which this permit is issued, I shall not employ any person in such manner" as to bec su ct W n's Compensation laws of California." Signed -- ---- -- =------------ ---- ----- ----- -------��lk---..-----------------._ Owner --- By - ----------------------------------------------- -------------------------------------------- 1--------------------------- _! -Q--------- Title ------------ ----------------------------------------------- ----------- (If other than owner) ,r FOR DEPA1tTMENT USE ONLY APPLICATION ACCEPTED BY ------ - ------------------------------------- DATE - --- BUILDJNG_PERMIT ISSUED .............. =:- = :_-___:._.-..,_.—^,=w:_.::�___r::: :_� - �rDATE....;: ------- ADDITIONAL- COMMENT ' '` -- - v ____ _____ _____________ __________ ___________.r . art . .a� --------------------------- . .�� = 11 ,. � � ---------- --------- -- -- -- s ---- ----------------------------------- -------------- 0---- - - -•------ Final Inspe - - ----- - Date y � . ----- -- ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M