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/ FOR OFFICE USE: FOR OFFICE USE - APPLICATION FOR SANITATION PERMIT . ' Permit No._�-�---"-6 - . _ (Coir,' a in Triplicate) __40 --- -- --_-"" - Date issued----/�-�� - --------------- -- - This Permit Expires 1 Year From Date Issued ---------------- --------- 1.R r }> the rmit to Application is hereby made to the lSSan Joaquin h County Health Destro. 549 and zist ng Rultes and,kegulations: work herein described. This application is made in comp .. - _ ------------- CENSUS' `�' q TRACT. JOB ADDRESS/LOCATION-- --_ .----- -- ----------=--------- k - = --- ----------- ------------------------------------------ anPhone Owner's Name ------------- --------------- - --- ------------- City--------------_.. +� Address------- J.� _/ * !-. V _� -- -------- ------ -----License #.�- -/f------ ✓ "d Contractor's Name.--""--- = 1 Residence ❑ ; Apartmenfi'House ❑ Commercial ❑ Trailer Court ❑ . Installation will serve: � y. Motel Other-._ ---------------- ----- yY m17er of living units:. -"- --.7 T-1-Number umber of.bedr.00❑mst._n _" © v s i � ' �' 4 `�- --Garbage Grinder-----""----Lot Size----- -------- -- Nu g j ,�J t ate riv I name------ ----- y:.,�� v Water Supply: Public System and i 4 t` ❑1 Sandy Loam ❑ Clay Loam ❑ Character of soil to a depth of 3;feet: Sand ❑ Silt❑ Clay ❑ PeatY e" ..__.. Fill Material..__"._-..-_If e`', type Hardpan ❑ Adobe ❑ I F (Plot plan, showing size of lot, I Icationrof-system-in-relatiori-to wells, buildings, etc. must be"placed on reverse side.) NEW INSTALLATION- `'(No.septic tank oq seepage pit permitted if public ewer is available within 200 feet,) Size----- --- - - -----------Liquid 'Depth. - - - - PACKAGE TREATMENT [ 'I SEPTICTpANK,![ ] I o p r ments.--- ` ..Mater"al__ No C m a t { Capacity t'-,-Type. 4 -- -- --- f t •=----Foundation_..-/•.--------------Prop. Li --- �- ------- 'Distance } Line - i Distance to nearest:[Well-..:._*- [ Length o I Total Length.. ! ----------------------- --------------LEACHING L1NE . .[a . No. of Lines..-. 1f each lin® .lJ lMaterial -- epth Filter a ----- � ---- , D' Box.4-------TYpelFilter Material- Line ' -Vondation----------------------------.Property Distance to neatest:.Well-------------------- --- . . _ Rock Filled Yes No ©� SEEPAGE PIT [ ] p - =----Dia eter.-- _ -- Number "--//--------- . f °�-�Ir-,,----------------------------- i7 .. = = Rock Size l- -------------------- Water Table Depth.--_-------- • � ------ --- Foundation--- -----------------------Prop.- Line-------- -------- � Distahce.to nearest�Well-.__€-'-�-- -" -- - ."--."" REPAIR/ADDITION (Prev. Sanitation Permit#- •------ Date-------------- ------ 1 ---------------------- ----------- ------------ Septic Tank (Specify Requirements)-------------------- - °-= Disposa! Field (Specify Requirements)-------------- -------- ------------------------------------ ----------------- -- --------------- - a --------- ----- ------ - R ---------- ------------------ = T i = ---------- r----------------- ] r ~' (D w existing and required addition on reverse side) with ance I hereby certify that'll ha'vequin County prepared this applicatiomanoft�heat tSan Joaquinwill Local Health District. Home owneQorJlicensed agents Ordinances, State Laws, and Rules and Regulations signature certifies the following: P 1 person in such manner as "I certify that in the performance of'the work for which this permit is issued, shall not employ any to become subject to Workman's Compensation .laws of California." , { -----Owner. Signed- i--=--=- ---- + --- ------------------------- - By------- ---4 Title (If other than owner) p 1 OR PARTMENT USE ONLY ` _ DATE. - ------ APPLICATION ACCEPTED BY ---- ' — - - ------------------------------------I----- ----- DIVISION OF LAND NUMBER.-_---------- ----- = - - ----- --------- ------ --- ----- ------ 4DDITIONAL COMMENTS..----=-`--'t------------- ------- ----------- ----------- ------ -- ---------------------- ------- ------ -------- --- ------- ---- 1 ------------------------------------- -- - -- t r ---------------------------- ------=------------ z--- �--- ----- ----------- ----- al Ins ection b , ------ Date - ------ AP F&S 21677 REV. 7/76 3M �3 24 / SAN JOAQUIN LOCAL HEALTH DISTRICT