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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 4 Permit .-----•----------------------- ---------- --- -...-... - No. -=1 -'•-� [Complete in Triplicate --------------- ........ Date Issued ............... This Permit Expires 1 Year From Date Issued Application is'hereby made to the Son.Joaquin Local'Health District for p mit to„construct,`and_install the work herein described. This application is made in compliance with CountyOrdiriance No. 549 and existing kules and Regulations: ^a JOB ADDRESS/LOCATION------ _. -...- - - -----..CENSUS TRACT % .... Owner's Name Phone ... r Z' ... ........ ..city----- ..--- Address-. ....License tor's Nate... Phone. W Contrac - �f ... 8 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court Motel ❑' Other........ ..... ------- --------------- Number of bedrooms..-....Garbage Grin ...Lot Size_.._-.� - = Number of living units------- ------ ••-- - --....Privy ❑ Private "Water Supply: Public System and name-- ----------------------------- °' s Loam CIa e Loam El Character of soil to a depth of 3 feet: 'Sand E] Silt E] Clay ❑ Peat E] Sand Y L ❑ Y Hardpan E] Adobe ❑ „fill Material - --. ..-.If yes, type---- _ I {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 seepage pit pbrmitted if public sewer is available within 200 feet,) '= 1 i Depth._............. .......... PACKAGE TREATMENT [ } SEPTIC TANK [ } Size ........ .. ......... --Liquid Matw•ial ..... ....... ...No. Compartments Capacity=,>��f/ ------TYpe-� G ... x _ Distance :to nearest: Well.....-- P __.Q Foundation------- '.. Prop. Line------------....... --- 6 LEACHING LINE [ } No. of Lines :- --Cngth of each line ...... Total Length 'D' Box........- -.Type Filter Material--- Depth Filter Material---------------- ----- - s Distance to nearest: Well------_........ ...... ...Foundation--::.- �--- T.Rr.operty Line--........ -- - - INumber --------- Rock Filled Yes ❑ No [f SEEPAGE PIT [ ] Depth--- ---Diameter-=---- ----- Rock Size.-. ................ C Water Table Depth--------• --------•-------- -- - ----------------------- ------- . ------Foundation ---...-- ....-.Prop. Line----- ------- ---- -------- Distance to nearest: Well--------------- -.-- -- - - REPAIR/ADDITION (Prev. Sanitation Permit#-------------- - f Date-------••----.. - Septic Tank (Specify Requirements)- '.- -- -- x 1 Disposal Field [Specify Requirements}...:. - -- - ------------- ---- - --- ---------------- ------ ------.....--- ------------- -- ----- (Draw existing and required addition on reverse side) aquin County 1 hereby certify that I have prepared this application and that the work' will be done in accordance with San Jo Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: M "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"f Compensation laws of California." Signed------- ------ � ---------Owner Title-- .......... Y - -• - (if other than Vowerj� R FO EPA TME T USE ONLY DATE j APPLICATION ACCEPTED B -------- DATE_.. ,_.. _.._ DIVISION OF LAND NUMBER..----- i - --- ......... - ------- -------- -- -- ......... ------- ADDITIONAL COMMENTS_...----- -------- --- ----- ---------------- ':--------------------- -------------------------- .---- - _....._ --- - ... tI --------------_`--- --- ------ -.. ---- - - 0�.... . r 1�l I ------- Date.... �” Final Inspection by:_--.-- -.- ----�G'? S-� �•i ��F8�5 21677 REV. 7/f6 9 # EH 13 24 SAN JOAQUIN LOCAL HEAL t RI� 10 , 4