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FOR OFFICE USE: t °2' 710 FOR OFFICE USE: APPLICATION FOR SA1/1TATION PERMIT --- ---------------- Permit (Complete in Triplicate) ------------------ _ 77 -------------------------------- - Date Issued----- --- - -------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Heal+h 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..----_4S._j - - -------- ---- - _ �.�. ✓ C�--- ------CENSUS TRACT- -•--- - ----------------- Owner's Name..._--_ ._. - _ Phone__- ._-___ A f,T-------- Address__. ------Address-- _.a140P_.6 3--------%5- ------ ------ ---_-City Ael$-G�.111,y---------------Zip------------- ---------------- Contractor's Name-----� fi-----4----- s7G. t!+,, --- *;Laicense #._ - -7/ Phone_�6,;?1�_Z1------- Installation will serve: Residence [Ej- Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other----- -------------- -- - -- ----------- Number of living units:__,-----Number of bedrooms...X----Garbage Grinder-- �_LOt Size----. - j &e� -------- Water Supply: Public System and name--------W-A//--------------------------------------------- --------------------------------------------Privatex Character of soil to a depth of 3 feet: Sand Silt E] Clay ❑ Peat❑ Sandy Loam ElClay Loam ❑ Hardpan ❑ Ado e Fill Material------------If yes, type---------------------------_--- (Plot plan, showing size of lot, location of system in relation to wells, bu)ldings, etc. must be placed on reverse side.) NEW INSTALLATION: {No septic tank or seepage pit permitte •�u c s 1 e�is (able within 200 feet,) Size._ _ �/ ----Liquid Depth _4 TREATMENT [ j SEPTIC TANK [ } - - ------- ---- -------------------- - ---- 7 e--' -------------0 Copacity. �� Type ' Material-.4 1_- o - No.-No. m artments----------------- --- Distance to nearest: Well--------- _-_tea--. -- --Foundation._----_ C --------.-Prop. Line---_�®----------- LEACHING LINE [ l No. of Lines.____..---a--------------- Lengtq of each line_---__ U -� ---------------Total Lengt -��_��` -----------------� : . D' Box--- - Type Filter Material�.� Depth FilterZterial_____________ . ____ _ -- ---------------------------� --------------- Distance Distance to nearest: Well____. __ ------___..Founclation___.__._ 0_________.-Property Line. _---------------- ---oc SE=EPAGE PIT Depth----------------Diameter--------------------Nurrlber---------------------------- ---- Rock Filled Yes ❑ No EIP WaterTable Depth---------------------------------------------------------Rock Size------------------------------------------------ Distance to nearest: Well------------------ -----------------------Foundation--.------------------- --.Prop. Line-------------------------- REPAIR/ADDITION {Prev. Sanitation Permit#--------------------- ---------------------------Date-__.------____._--_--___ --------------------) Septic Tank (Specify Requirements)----- `k•F'�1_._. .Uf L-------- -� --/'z 4. >. Disposal Field (Specify Requirements)------------------- - -- -------------------- ---------------------------------------------------. `--------------- --- ------------------------------> ----- -------- ----------- --------------------------- ---------•---------- --- (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 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 subject to Workman's Compensation laws of California." Signed----------- -- ---------- ------ ----- °- - ------------- ---- -------------------- ----------_Owner ` Title---- - B Y----- - ---- --- `F (If other than owner) F EPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- c�-_--- --- DATE -- -- -1 7- --------- - - - --- DIVISION OF LAND NUMBER .. ----------- ------- ---- - -DATE----- ----------- ----------------------------- ADDITIONA COMMENTS Lz�-ll�t`�-__ r_��,P ------ -- ��--- -- -�- --- -------- ----------- �---------------- - C�C - 'c rte.. _ --------------- ------------------- -- ------------------------ ---------------------------------- --- ------------------------------ -------- - -------------------------------------------- -------------- ------------ --- ----------------------------------------- - -- ' ----- ----------Z-------------- ---------------------- ---------------------------------- ..__ ` -------------------- -- ---- ---- ---- ------- ----- --------Date--- 1 ---- Final Inspection by____________ _____ ______ _�- - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M