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/ F R OFFICE USE. b _ T '=. .7 v - = --------- _ __ -- APPLICATION FOR SANITATION_P_ERMLT �� c ��"fel -=----------------------- -;' [..' p A I -- fCb m- fete in Triplicate) i f Permit No. — -----------------------21 This Permit Expires 7 Year From bate pssue-d 1 Application is hereby ma�e to the San Jo Date Issued I described. This application is made in comp ce al i health CounDty t0 Ordinance No. 549 permir^'to construct and install the work herein JOB ADDRESS/LOCATI and existing Rules and Regulations: Owner's Name _CENSUS TRACT _.. T _--- --- ------_-- -- ------ - . Address X19/ - 4 t ____._:------------------- - �� /-� -.Q.�� _,,�� - -------'�--- --Phone.�,�3_� .. Contractor's Name __ f }– --�.`r'� City- ' .�T�l Z : _______________ 1 _.Lfcense # ! - Installation will serve: _ �� Residence I------I- Phone ._. _--_ Apartment Hou se�Q_Commercial Trailer Court ❑ � -z— -, Motel IrCI Q ❑Other "t t . Number of living units:_------ ; Number of bedrooms _._ r - -------y.__-----_--- ----Ga;r`b ge Grin Water Supply; Public System and name - --- Lot Size Character of soil to a depth of 3 feet: S € ............... -- -- and'Q Silt Q Clay Q1 Peat Q Sandy Loa Q --CIS -------Privvate Q Hardpan Q Adobe Y'Loam a Fill Material ______-___ _ ff es (Plot Plan, showing size of lot, location of system in relation. to wells; buildings, etc,I type _________ _ _____ NEW'INSTALLATION: � [No septic tank or seepage t permitted Wpublic sewe�is availableiwimust bhin 200 placed °n reverse side.) PACKAGE TREATMENT Pi P Q ( � SEPTIC TANK'[ ] � - feet,l i Size---- ------- ----------- Liquid Depth ---- Cap I�city -------------------- T j i L-1 --------------------- Type - Material---------- Distance to nearest: Wel! No.j Compartments LEACHING LINE 011-f � -----w� Foundation.__=_:__:_I [ ] No. I�f Lines ------ - - ---------- Length of each line------- __ -- Prop. Line __--•_.--- Box T '� ---------- Total Length ------------------------ D' �� Type Filter Material ____..--_„_~-_-_-Depth Filter MDistadateejaf _____________ ce to nearest: Well ........................ --------- --- ••------ SEI=PAGE�T pFoundation ----------- -----! Property Line -----•--- -----_tl Number -------------- -----�Rack Filled Yes F j Waterl�Table Depth ____-.--------------------------------------- Q No .iQ _.Rock Size f REPAIDistance to nearest: Well _-____________________ � - ------------Foundation ---- ---=---- ------ Prop. Line ---------------------- RJADDITION(Prev. Sanitation Permit# -_---_--_-__- IIM, � --- ------ Date _.� _ 1 _i_tt._. = -- ---- Septic Tank (Specify Requirements) ______________ f _ I I Disposal Field (Specify Req', --------------- - a Y'`: --------- ---- -----,--------------__-_-- --------------- --------------- ------ dal �. - - - - -- ---- ------------------ X- , ' ------ --------- --- -III-- - -- - -- --- -- - - --- ---- - ------ -_-------- ---------- --- ------------ - -I f (Draw existing and required addition`on reverse side) l f hereby certify that 1 have prepared this application and that the work will be done inaccordance 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 th'e following: "I certify that in the performance of the work for which this permit is issued, 1 shalt not employ an �- as to become subject to Workman's Compensation laws of California.” y y person in such manner Signed ------ I� Owner 3 - -- ------- - ----- ------------ ------------ BY --- � - ------------------ Title ------- ��a-'l (If other t owner) "'--� ' i FOR DEPARTMENT USE ONLY APPLICATION ACCE ED BY L"r _ BUILDING PERMIT ISSUED -------`M DATE _. __---__ --------------•- ------------------------------- -- - ------------ '" ------ r -------------------DATE --- ---- �. ADDITIONAL COMMENTS __ I_I i 1 : ---;--____.____.,_____ . � = ------------------------------------------------ -- I' --------------------------------------------N _ _________________________________________________________________________________________________________ Final inspection by; - Date _L _.L �, SAN JOAQUIIv LOCAL HEALTH DISTRICT E. H. 9 1-'S8 Rev. 5M