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L_uFOR.OFF[CE USE: _ -- APPLICATION'FOR SANITATION PERMIT FOR.OFFICE.-2-'� '`�""" USF: -- (Complete in Triplicate) Permit No.._--_---------- ------------ This Permit Expires i Year From Date Issued Date Issued---cP-.�_�"_'_7Y Application is hereby made to the San Joaquin Local Health Distrctt for permit to co struct and instal! This application is made in compliance with County Ordinance No. 549 and existing Rules and ReguJatioris: - the work herein described. �. ., JOB ADDRESS/LOCATION --------------- ------ - ' Owner's Name ------ .CENSUS TRACT___________________ ------ Address - '---- -------- _.- Phone _ .. � -- -� -(/ -- --(� - ---- icy--------------------------- ---- -- � - ---- - -- . Contractor's Name----- t ZiP-- - Installation will serve: p -License #- _- ` Residence Phone._-Y-,3- ❑ " ❑ ❑rt Other-.-.',House.[:] Commercial ❑ Trailer Court ❑ Motel-� Number of living units:__'_.---!-------Number of bedrooms-__ Water Supply: Publi .__.. ___Garbage Grinder___._----,"_Lot Sizec 5ysfiem and name___.. ---------- __ # T --------------- Character of soil to a depth of 3 feet: : Sand ❑ Private ❑ [ Silt❑ Clay ❑ Peat-- - "-Sandy Laam ❑ 'Clay Loam µ .� ;Hard an - ` .� _.. - . P ❑ Adobe If yes, type_.:-------"- ❑ Fill�Material__._. (Plot plan, showing size of lot, location of system in relation to wefts{bu�ldidgs, etc.:must be placed on reverse side.) NEW INSTALLATION: :(No`septic tank or see a e it ` P 9 .P permitted if public sewer is available within 200 feet,) � PACKAGE TREATMENT [ ] '` SEPTIC TANK r [ � Size ' _ ----------------------Liquid Depth----�-- Capacity.41_0> -:Type • --- ---- - -- Material-- - Compartments_:' I t I N o. - D�stance.to nearest: Well--------'-„ -fy LEACHING LINE Foundation._ _A0-----------------Prop.-Line------""-�-------- n [,J No. of Lines , gfh of each line..----_ _�`1 Total Length.-t-70 D' Box /------TYPe Filter Material_ ' " , - ------ ` Depth Fifer Material_ ., Distance•to nearest: Well-__ ;- . , n> ".'Foundation-._,-- : SEEPAGE PIT --P Line _ . .. Y. _ __________________ ____ [ l Depth__--_ roperty L' -dam Diameter_.,-=—y"Numk�er___--- _._„ _` Waterf9' Ib Depth---------- k ye ❑ - N ------------------ b Roc Filled s � i. �+ u 0 . �`� � -Roc-k•SSize _--f - Distance to nearest: Foundation_-`� ---- - r. REPAIR/ADDITION-(Prev. Sanitation Permit i- °, ' " " Prop• Line ._ __. '------------------ --------------------------- =--------- -- ---------Date---- ------------------ ------------ --- Septic lank (Specify Requirements)_=_ __ _ _ ------- Disposal Field (Specify Requireme.n r t ------------=- ------- ------ ------ ------ ---------- . - = ----------- ------ -------------- - ` - = -- -------- - ------------ =--------- -------------- (Draw existing and j`req uired addition on reverse sid= e} - I hereby.certify that I have prepared'this:application and that-the work will be done in accordance with San Joaquin County Ordinances, State .Laws; and Rules and ;Regula#ions of the San Joaquin'Local Health District, Horne owner or licensed a ernry signature cerfifieSLthe following: . I - '► 1 _--4� ; g is "I certify,that in,�he perforiiipnce of the work for which this permit is issued, 1 shall not em to an to become s% iect to Workman's Comperiscition laws of California.". _ p y Y person' in such manner as Sighed_--------- By -` rf r , - ----- - - -- --- ---------Title------ ----- ----- ------ (If other than owner ,. ------------------------------ - $ # # O DE ARTIVIENT'IJSE ONLY APPLICATIO 'ACCEPTED By --__- --- ------ OFAAND NUMBER-� = _ �"----------- DIVISION .................... D -- 3 ADDITIONAL-COMMENTS--- -- --- J� s - D E-__-- -- " -- . ------ ---------------I------------- -----------:-------- ------ --- --- ----- ----- -- - . . ... .. .. ........ -- t ----- -.. --------- ------------------ ------- -------- ---- ----------------- --------------- rf`. ------------ ---- - F Final Inspection b -- - ---- ------ ----------• --------------------------------- ' a 7 erg 13 za ------ -;---Date�°----' -- - - -'��--- �---- -- SAN J AQUIN LOCAL HEALTH DISTRICT i F&S 2r 677 REV. 7/76 3M