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=� R OFFICE y E: ��— FOR OFFICE,USS:,.— APPLICATION FSANITATION PERMIT --- -t ---- --- .� (Complete in Triplicate) Permit No..��7 a2 _________ _____ This Permit Expires 1 Year From Date Issued Date Issued_.'7`-�l � -- `77 IN Application is hereby made to the Son Joaquin Local Health District.for a permit to construct and install r c Abed. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulatio B ADDRESS/LOC ON i rl �� t CENSUS TRACT -- - ---------- ------------- JO �F.: i - Owner's Name.:----- --' Ali! e�� ------Phone-- - hone- — ` . , - _ ----------------- Address -------------- - Address-------------------- --!Ig �.• .!City -----'-- --- - - ------- ---------- s ntractor s Name_.:_._ L - --- ------------ i ense # --------- -- -- Phone--. �" �Q7------ CoL'c I � Apartment House Com.mercial Trailer Court ❑ l Installation will serve: Residence F] E]Motel L] Other----------------------------------------------r:' $ �(�/ ?Q: w i f { I ' ' --- # Number of living units:_ ____ _ ___..__Number of bedrooms_,_.________Garbage �r�n er---�_-..:-__-Lot.Size__.. ,I ----- -_4 -.I-- -------------- - -- ; ,� L Private`- Water Supply: Public System and name___.._ -- ❑ Character of soil to a depth of 3.feet: Sand ❑ Silt❑ Clay ❑ Peat ❑,,* Sandy Loam 0 Clay Loam ❑ Hardpan ❑ Adobe Fill Material-"__'...... yes, type------------------------------------------ (Plot plan, showing size of lot, location of 5'7itemin relation to wells, buildings, etc, must be'placed on reJerse side.) NEW INSTALLATION. -'(No'septic tank or seepage :pit permitted if public sewer is available within 200 feet,) NT ] ]' SEPTIC TANK g - Size----- " ---- -- -- ___ _ _ qDepth. I�I _Material_____ No. r PACKAGE TREATME Capaci4;y ;Type__ - - ------ - --- IM f� -: Com artments--- �1' -- I" t ; 'Foundation 1� ` Dd Distancl�.to.nearest: Well-�-------�----�-----------r= �� - �- --.Prop.Line- ---- --------�----�--- i LEACHING LINE No. of Lines_.- ` C Uig '9 .. L Length of ea . line. L3 Total iLength r ----------- 0 ---- --- G D' Box_--:.dW___Type Filter Materia.L._, dr.�sr-__D pth Filter Material- ._ ti_------------------------------------___ r . i _ a. i Distance to nearest: Well- ------- ------------------Fou dation---_-=�o -f--------Property Line.-.- ------'`--------_------------ SEEPAGE PIT De th...Z = _D.iameterumber-------- -_.__ X s p j? f Rock Filled Yes No , D rater tan eatol nearesh: Well - Rock Size jV // t - -,-- E'""Foundation --10---f-=--------.Prop': L'ine--------�.'- -------------- REPAIR/ADDITION f REPAIR/ADDITION {Prey. Sanitation Permit ------------------ ----- ------ ___-- ------------------.___l_) I� Septic Tank (Specify Requirements) - i--------- ------=-- -------------- --------------- ------------ - Disposal Field {Specify Requirements):------ - -1 .- nN :r° ---------- --- - ------- ------------- -----:-r ; ---------------------------------------- =-----------=----=-- ---------- ------------------------ - - --- --:.-- '---------- -,---------------------- ---------- ------ __ rtC._--- --- --- --------- - ------ ..(Drew existifng and Ireclutirecl addition on reverse side) hereby # ' certify that I have prepared this application and that the work be done in accordance with San Joaquin County Ordinances, State Laws, and Butes -and Regulations of the' Sari Joaquin Local Health District. Home owner or licensed agents signature certifies the following "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation I laws of California." t i ' Signed - - Owner ._' - , BY------- - ---- r t -.Title ______ ________y. .. _ _ _ ____ _-.---.._____. -------------------- --- ...._ r Iother than owner) ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- - ----- --- ------------- ------------ - = DATE. / DIVISION OF LAND NUMBER. ----- --------------------- ---------- --------- ------------- --- --DATE- ---- ........... ---. ' -----=---------------- ADDITIONAL COMMENTS__...._�M.- _ t �- 't ,!�►.. _�-_. v �� ---------------------- --- ----------------------- _--� - - r �-c � ------------------------•--- ----------- --------------------- Final -- --------- -- Final Inspection bY. Date5 EH 13 24 4 rAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M