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FOR OFFICE USE: APPLICATION,FOR SANITATION PERMIT ---------------------- (Complete it Triplicate) Permit No: / � --------------- -----_ bate Issued (_�'�_ :- This permit Expires 1 Year From Date Issued Application is•hereby made to the San Joaquin Local Health District for a perr'nftl ta_eonstruct and install' the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: 3 JOB ADDRESS/LOCATION - - --��-------- -��-�- ----1�1. _ 1�----..CENSUS TRACT` _E�`��--- -- Owner's Name ----------RI--c_H_JgRD---- ---- 1 'NL1�t`1 ----------------------------- -------Phone 52 Address - ------ - Ga------ � `ate l l� _1 -------- ----------------------------------- city ---14�4��s`�--• - - - Contractor's Name -----61iL,FrJ_,F_:f ,`--- ------- -----------------------------------------'-------- --------License # --------- ------ Phone ------ Installation will serve: Residence rA-partment House' [] Commercial:❑Trailer Court ❑ Motel ❑Other_ ' ----------- I r Num6;r' of living units:____ ------ Number of bedrooms . r T -_____Garbage•Grinder•_ -0---_ ' -- -_ Lot Size __�C-(��R-E Water Supply: Public System and name ---------------- ----- ------ i '. r ;- y ------- �` L_ Character apili-to a depfh of 3 feet: Sand' Sift. Private _ ❑ ❑ Clay ❑ Peat 0 Sandy Loam Clay Loam;❑ •� .. - ��..� .. ,-�. � r era l Hardpan ❑` -Pdfslae ('] ' _ at r I r��i_-lf-yes:type'__.--~ SFr 1 .NI (Plot(plan, showing size of lot, location of system in relation toYwelis;b'urlding-s, etc. must be placed 'on reverse side.) NEW INSTALLATION: ! , de.) 3 {No septic tank or seepage pit permitted if public sewer is available-Within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK � Sizes-'------------------------------ Q ----------------- ---- r- •, Liquid De pt - -' ---------Ca acitY -------------------- - TYPe ----- Material jj' nompartmets - - 0 �, Nofir � _ .---� narest: Wellstance _ Foundation Prop Line LINE - J Le6gth'df ea�h-line ] Total Length l` _ - { ------,----- --- i D' Box _---- Type Filter Materia _'� -I" 'Filter Material_ __ Depth Distance to neareslt:r'Well Foundation ---t ------------------- Property------------ _ - -----=----- t---❑ SEEPAGE PIT [ ]; Depth t roperty Line P i - _ Diameter ---------------- Number ------_-'-y- ---a --=_-._- Rock Filled Yes No .0 P Water Table Deptlt —_:- ---------- r , Distance to nearest: Well ___________________ Foundation `' I ---------------- -----. Prop. Line .---------------- REPAIR/ADDITION(Prev. Sanitation Permit# --------- ------------------------------------------------ Date ..................... } Ll Septic Tank (Specify Requirements) _____________________ ------------------------------------------------------ - Disposal Field (Specify Reirementsli ----------------------- -------------- Ing---=---6F �;y •L��_�l� �I IV ----------------------------- ---------------- - ------------- - - - ---------- ---- --------- ---------- 1-4 --- ? (Draw existing and required addition on reverse side) hereby certify that I have prepared this application and that the work will be donein accordance with San Joaquin -County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local He .11A District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not eiEk as to become subject to Wokkmiso an's Compensation laws of California." ,-p y any persons Tot such manner n Signed ---------- ---($1---- ---- -------- --------------- ---------- - Owner BY `--�--tea-'`cam _- -- � I , - ----------- Title - ; (If other than owner} -------'---------- -- FOR-DIEPARTM'ENT-USE'ONLY »— APPLICATION ACCEPTED BY`-'--` G" PEIR7I��IT-iSSUED�:'-"'=-�---�-t-i-�- ----�••- . =-- ----------------•- DA TE -----T_/ + ADDITIONALCOMMNTS T -- --------------DATE .----=---' - -" --------------- - -. - ----------------------- ---------- -------------- R - --- - ------ ----------------------------- ------------------------------------------------- -- - - -- --- FinalInspe -------- ---- ---- ---------------- SAN _` SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b$ Rev. 5M r.