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At FOR OFFICE USE; FOR OFFICE USE- 1. SE: }} J M APPLICATION FOR SANITATION PERMIT �7, f { Permit No... ..--- - 1 {Complete in Triplicate)' - ---------------------- �''� 7Date ]s ued-'. -�'-�� --------------------------------------------------------- This Permit Expires 1 Year,From Date Issued Application is hereby made to the San Joagui Local gBoith District for a permit to construct andinstall the work her descried. This application is made in compliance with County qrPlifiance No. 549 and existing Rules and Regulations: r JOB ADDRESS/LOCATION___-_....- q / / f --- yt1fC1'�1--------- --------------CENSUS TRACT Owner's Name. find ------- ------- ---------- --- -- - ---------------Phone. r Address - _klp 'i-)---- -- ....- . City. Zi.p -%: - . --- --- Contractor's Name. gr• --. G I- - ----------------.License # ......... ------ -------Phone --------------------------------I Installation will serve: Residence ®' Apart(nent House ❑ Commercial ❑ Trailer Court ❑ Motel E] Other-----------------------__- - --------- _ Number of living units:...... F--------Number of bedrooms--.__Garbage Grinder- - - ----Lot Size________- ---------------------- --- --- Water Supply: Public System and name----------------------------------- --------------------- -- --------------------------- ------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material............ yes, type-------.---_---._-- ------ IN 9t __.._IN9t 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 seeRage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT ( ] SEPTIC TANK- Size a� /r ... Liquid Depth -------------- ' Capacity - Type-J04 Compartments151-1 ---------- �.. Distance to nearest: Well.---.(O j-----------------------_---.Found --- ---- --.Prop. Line..--70..- -----------.Z LEACHING�lNE [ ] No, of Lines-----.�- ------- Length of each line..'/Q .....--.Total Length ----------------- R. 'D' Box__ ----.--Type Filter Material_ 4; '_.Depth Filter Material----------0/5�-----/j----------------------------------------- DistanceAto nearest: Well----____.--_----- ---- Foundation----------------------------Property Line--.----._--_____---_ --_ _1e ~ } SEEPAGE PIS ] ] , Depth----}-----------Diameter--------------------Number.------------------------------- Rock Filled Yes ❑ No-T WaterTabl/Depth --------------------------------- ---- ---- -----------Rock Size------------------------ ----------------------- Distance t6,nn6drest: Well-------------------_---------------------Foundation--------------------------Prop. Line ---------------,- , _.. REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------'---.Qate..--...__-____.-..------___-___------- -- Septic Tank,(Specify Requirements♦_------t<�t --------------- ------------ Dis I Field {Specify Require m nts)---1--------------- --------------------------------------------------- ------------------ - ---------------- 7 i ------------------------------ ----------------------- -------- -------- ------------------------------ - ----------------------------- ------------------------------------------------------------- '— { raw exexisting 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 ' +' d,.sand Rules and Regulations of the San Joaquin Local Health District, Horne owner or licensed agent signature ci rztii h following: "I certify f in a rF m 9ke of the work for which this permit is issued, I shall not employ any person in such manner as to beco nfan' :Compensation laws of California." Signed ---- --- Owner ' BY---- - -------- - -----------L=---- -------------------------- -----------------r------------- ----Title-- ------------------ ------ (If other than owner) fFOR PARTMENT USE ONLY PI- APPLICATION ACCEPTED BY --- --- - -- ------------ ------------- -------------------------------------- DATE. J DIVISION OF LAND NUMBER. ---------------"- -------- ---------- --------- ----- DATE--------------- -------- - ---------- ADDITIONALCOMMENTS----------- --------------------------------------------------------------------------- --- ---- - r ------------------ --- ------ ---------------------- --------- -- --- -------------------- -------------------------- ---------------`----------- -------- -' --- ------------- T---------------- --- ---------- ---- ----------- - - ------------------ --- -U- --- - »----- ------ ------------ - -- --------- ----------------------------------- -- -----------------------------------J-- ODate Y. ----------- Final Inspection by - EH 13 24 SAN AL F&S Rev. 7176 3M