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h. FOR OFFICE USE: "t4r, -.1 1 FOR OFFICE USE: APPLICATION FOR SANITATIONPERMIT t 7 -�Q 5 ------- Permit No. F (Complete in Triplicate.) ANIL ` ------------------------------------- f -/7- ear ! ` 1 Date Issued �_-�--This Permit Expires 1 Year From`Date,ssued 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.-- _---.CENSUS;TRACT----- - ----------------- ----- Owner s Name----------- l ------------------- Address --," G'f' e*i � ._ =� .r ' ` City- ' z 1 � i - - Zip Contractor's Name 1 � �€ ' t� '" -----License # -v)! _ _ Phone - / ./ or 004 Installation will serve: Residence Apartment-Hou e El Commercial TraileCo ❑ i Motel ❑ Other----- --------------------- ---- E Number of living units-----------------Number of bedrooms -- Garbage Grinder------------Lot Size- e -- WaterSupply: Public System and name-.--:------------,f.`�. ; ------------------------------------------------. Private ❑ . Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay E] Peat ❑ Sandy Loam'❑ Clay Loam ; s Hardpan ❑ Adobe❑ Fill Material------------If yes,type- -------------- f � (Plot plan, showing size of lot, location of system in relation t wells, buildings, etc. must-be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ` ul PACKAGE TREATMENT [ ] SEPTIC TANK [•} - � e 0........ '�- --------- q p Size---- Liquid Depth �- �-- '------ --- � - Capacity!-ttt� ype. -Material--t--- Distance aterial--t lo_ Compartments-------- =------------------- - Distance to nearest: Well......Xe---:----s------------- Foundationf--- -----------.Prop. Line_Z1G----------`---. 1 LEACHING LINE [ ] No. of Lines.------: --------- ----Length of e ch line-- .--'---.Total Length -_:-- - --------------------- ' =--TY.P Iter�Material °r" Deptli Felt ater flt ' '" ___- -- ---- C D' Sox-_ . . �+ . ' y ----Property Line Distance to nearest: Well---77- =_.-- w_�undation---- �^ SEEPAGE PIT ] ] Depth_ _r-___Diueter �- *� N b40Gye__ ---------------- y� Rock Filled Yes ❑ No ❑ Water Table Depth - Rock Size ff Distance to nearest: Well - - -----Foundation--.--------.............Prop. Line--_,e0V----- I REPAIR/ADDITION (Prev. Sanitation Permit#_.----- `- .-Mir-""'--_----- lr Sate---.--.___..----__ -------------------- ----------- -----] Septic Tank {Specify Requirements)----------- ---- -- --------------------------------' - -------------=---T.-------------------- ----- Disposal Field (Specify Requirements) - ------------------- --- -----------------------A ------ -- ------------------------------------- t ' --------------------------------------------------- ----- 3 ------------------=-------------------------------- - ------------------------------- _ ik ---- ---------- ----------------- ---------------------------------------------------------------`----------------------------:------------------ --- {Drow existing and.requ'i ed.yaddition on reverse sida)�. I hereby certify that I have prepared this application andithat 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: N "I certify that'in the performance of the .work for which this permit is' issued, I shallll,not employ any person-in.such manner as --3-1 � to become subject to Workman's Compensation laws of California:" Signed- --- -- ---- = ------,Omar t aY -----.Title.--:�' � �'fr'Y_. ` � (If other than owner) FOR DEPARTMENT USE ONLY' �.. ��. -a---- -----------' -------:------- --------------DATE.__ --- - 7 ------------- APPLICATION OF LAND ENUMBER------- - ------- ------------ - ------f_ ---�' DATE --- DIVISION :----------- ------ ----------- ADDITIONALCOMMENTS--------------------- ----- - .a----------- ---------------------.---------------------------------------------------------- : I W ; . -------------------------------------- ---------------------------------- --- - --------------------------- !j /f ------------------------------------------ - Final Inspection b �-- --------- ------------------- --Date. . �-. ------.-� - EH 13 24 SAN J AQUIN LOCAL HEALTH DISTRICT F&s 21677 REv.