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FOR OFFICE USE: � FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------------ (Complete in Triplicate) Permit No..;7, -t;e,_ _ ------------ -------------- ------ This Permit Expires 1 Year From Date Issued Date Issued-_= = �' -1 Application is hereby made to 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. 549 and existing Rules and Regulations: T_ . ,,�•_4 JOB ADDRESS/LOCATION---- - �(} DA Pl, - I. Owners Name_ NAL. ---� Ph _...r "- -, ENSUS TRACT.--I---- - ---- one- � ']` L ;d t Address------ -: -�- '' = --t�y�---.��r'��.��,Q-' �/'��. . City .hll� `. -- ----Ziff Contractor's Name. - - - `-L? =1 ------- License # *� � --Phone__! - - -- ---- ---�-- Install tion will serve. Residence Apartment Hd a.❑ Commercial [I Trailer Court ❑ r 4 • 4 Motel ---- Numb ❑ =Other- � ------= ------ --=---- ---- `---._ _. Water uppl : Publics stem Number of bedroo _--Qarbage Grinder Size------1l� - um er,of livor units:.-- -- --. - ---• -------- -- �•- ------- -- g y y and name = : ----- - ---- -- -Private Charade of soil to a depth of 3 feet: Sand ❑ 'Silt❑ Clay ❑ Peat❑ Sandy Loam X Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material_ ---------- yes, type-------------=--=-v-.---------- [Plot pl! n, show.ing size of lot, location of system in relation to wells, buildings,etc,must be placed on reverse side.] (] } NEW INSTALLATION:" :(N67septic tank or"seepage pit permitted if public sewer is avpilgble within 200 feet,) PACK GE TREATMENT -( ] SEPTIC TANK l�] Size__,-: --- ---- ----Liquid Depth- '' ------- - Capacity ype A- No.-�' '`�"- T � Materiai- No: �m artments_-`_ - _ ` -- �-=-------------------F undatio .-_ -x._- c�Cs L >; an ce•to,nearest: Well___..-- Q LEACHING L1NE; =[ ] Nof lad es.. !9 il IF g Prop... e_---- --------- ----- Lin ---- -------------'Length of each line._---- . Total Len th.'___�_ _------:------ YP f th Filter Mat ri 'D Box__- T a Filter Material--.A :oun �. Distance to nearest: Well . - dation _ _ p Y __ - Pre art Line- SEEPAgE PIT [ ] Depth.- D'ameter "� ------------------- _.Nu er �' Rock Filled Yes❑ No ----- ---- ------------- Distance - --=------------ ¢ Water rDel Rock SideDistan eatol ri .. - l crest: ell:` ;- -----:--- �- -------_ _ Prop. Line :Foundation ' a REPAIR ADDITION (Prey. Sanitation P Date = -----------------------_1------- Tank [Specify Requirements)------ ---- ----- - �—s - R . :. Di I Field (Specify Requirements):, ----.- . _ t ------------------ - -- -- ---- ------------------ y-• . ---- --- -------- ---------- ------------- -- r - ------- - --} - - ---- --- ------- - -- -S.__--_- ------- -- ---------- ---- ---------- -- r l (Draw existing and requ'ireddaaddition�on'reverse si, -) X I hereblr certify that I have prepared this application and that.the work will be clono, accorda_accordance with;Sanl.Ioa uin County Ordinances, State Laws, and Rules a� gulations of rthe' San 1 ac uii yI co al��Flec>�It Diitrict:Flom) w e� o?' ice sed—a ants ' \I t. .f y: ,, g signatu a certifies the following: d,�p "I certii, that in the perforrriarice of theorf wh'Icfi this ermiTi p s�sed�y``Jf shallnof'employ any person in such manner as to bac me subject to km s Com anon laws of California.';' Si ned- . ' t` ---------- By - Ow g i � -- --- n ► t } r B ------ ------------ ------{----- - �. -------------- ------------------------------- Tule --------- Y (If other than owner) : . ..,.- f i; . FOR DEPARTMENT USE OVLY'� APPLICATION ACCEPTED BY___--_-- �_.; . '.DATE.:= -� -� ---------------- DIVISION OF LAND NUMBER.-- ---=---- ? I DATE_. ,, ----------------- ------j ADDITI NAL COMMENTS-..---- --- 1 -- - - ---------- ------- ------ - . . .,. ----------------------------- ------ -----------------------•------------------------- - ------ ----------- ---- -- --- --- - ------ -- - Final Ins ectian b .. s _..R_ -------- ---Date-. ~` ' EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M