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' FOR OFFICE USE: I y` FOR OFFICE USI:: APPLICATION FOR SANITATION PERMIT I� .l �[Complete_in Triplicote3 Permit No,/ ...........��........ Date .44?A./ ----------------•.-.............................!I.....__ hKS1:0ermit Expires 1 Year Frorri-.Date Issued Application is hereby made t i�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. 544 and existing Rules and Regulations: JOB ADDRESS/LOCATION----__- •- -------------- . .._._ j --- --- ; CENSUS TRACT.... •-••---------------------- Owner's Name- hone .... Address_ o s rm_ /� d s. � � f ^�� ► f �y f Contractors Name - - ---- ---------------- ` . ` is �7d _A Phone- 54S�.00.�( ,............................ . �.....L' en se #••••-- •-... :• .Ph -' .....�-...... *a•- •. Installation'will:serve: Residence❑ }Apartment Hausmmercial Lj Trailer Courr' j Number of living units:..!.__._-:_l;___Number of bedrooms ., ar-bage Grinder.. _'_L.,_Lat Size__=- • Water Supply: Public System a�d n me.. - -------------------= ..- ---------- .. .. -------------.Private Character of soil to a depth of 5 feet: Sdnd Lj Silt❑ :Clay❑ ' Petit❑ Sandy Laam ❑ Clay Loon Ll - - -.---..w-_- Hardplan ] Adobe- Fill Material...__F_____-If Yes,tYp -------------------------- (Plot -----------..............(Plot plan, showing size of lot,!location of system in relation to wells, buildings,oc. must be placed on reverse side.) r NEW INSTALLATION:' (No" s1ptic'tan'k':or-seepcige pit permitted if public sAer is available within 200 feet,) PACKAGE TREATMENT- EPTIC TANK Size.._ r �quid`Deptl�i7. }u- l� ,�. - D Capdalty- � : TYp �C --•--MaterlQl.. ,_No. Compartments...----.. .. t 11 -. � .�. o f � � � . 'Distance to rieprest:.Well. ..�I' �,...... , .----.......Fou dationf _._ ,....--:.......Prop Line. .-.- � ir LEACHING LINE(Pr No_ of,Lines-L--� Length of each Iirre.. ,�;� #_-_-- - == m_ TotaI Length. -------------------'- D' Bax-.------- Filter Material s� Depth Filter Materials__:-_--: .f��.. >< Distance to nearest Wel ..Foundation---� .................Property Line_.:s SEEPAGE PIT [ Depth).a`a ....Diameter..-�U_.-------Number...:__ ..---1...._ ......_ - Rock Filled Yes Na❑ t Water) Table Depth....... ---- ------ Rbck Size , f r� Distance to nearest: eft'r' �3' "_. '`----------------.Fo�naario �--- rP op. Lme` �r--•r •_E... i REPAIR/ADDITION (Prev. Sanitation Permit- ------ -------------------"---}..........:-...__.Date....:...r..------'r------_- Septic Tank {Specify Requirements] - ,____ iI =x ; ------------------• -j--------=•------ .........•• •;� --- .-.------moi-------------------`--- Disposal Field (Specify Require nts)'___-__r--., • _ _: ,---........-•----•-•- ��'' F ,r --------- -- ------- . _ .. _ ...._ .�, ....... ......... .................�.............................-....-:_ ._...............------.-- .., . . ) , - --------------- ��` 1 (Draw existing and required addition on reverse side + r� I hereby certify that I have prepared this application and that-th;�! 'work will be done-in accordance-with Son Qquin County Ordinances,. State Laws, andl�Rulas-and Regulations of the San Joaquin Local Health District, Home owner or licetrsed=agents signature certifies the following: ''?-i "I cerci that in the i� 5 certify performance of the work For which this permit is'issued, I shall not employ any person in such manr}er as , to become subject to Workman's Compensation laws of California.'. Signed Irt--,---- _.. . --- - .. .-_ -•--Owner s ~ 4 --'�- gY .... . •-•-_... ... _..• - r. (If other than Zher} "' ' ._.. r -FOR DEPARTMENT-USE ONLY' APPLICATION ACCEPTED BY-'--.- ----- --•-•:••• `r.� : .. :-••••- -- DATE . DIVISION OF LAND NUMBER:- -------- ---- = -•_-•.................. y A ' ••::- D TE :.. ADDITIONAL COMMENTS-__1... --..... .. .. ...-•••. . .. . .. - �`... f . .......................---------------------------------------------------------------w.................................:-------------------------------------- ----------.•------...._-• ••• ry� ....___...._ ____p_.._.{...._.__._....______....__--________-____....._----.__-_-------------------_ ... _ ._.,ar .. Final Inspection•bY= -' ----------------- ------. �.:....................... .Date...'..... -------6V ------------- ........ - EH 13 24 I� SAN JOAQUIN LOCAL HEALTH DISTRICT FdS 21677 REV.7176 3M