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i FOR OFFICE USE: -------------- APPLICATION FOR SANITATION PERMIT FOR OFFICE USE; I (Complete in Triplicate) Permit No7,v-.-c��- "--- --------- --- This Permit Expires I Year From bate Issued Date Issued. Application is hereby made to.the San Joaquin Local Health District for a permit to constructand install the work herein described. r This application is made in compliance with County Ord' once No. 549 and existing Rules and Regulations; JOB ADDRESS/LOCATION ---/11� " ©�("- 3 roc 2} ,-b.- -- --- .CENSUS TRACT....----•- Owner's - Address------- r a.. _ ----..Phone. 6. . .. ... c; l - ty .. Contractor's Name.. f��c-i-_.. Zip ► ,r, ---License #-. . •a ...Phone.._.--= Installation will serve; � -_-" .-..----" -. "." "-_.- �- - Residence Apartment House -� Motel ❑ Commercial ❑ Trailer Court ❑ ❑ Other_ ..... -- -- . Number of living units:._.. .-..------Number of bedrooms-. Water Supply: _. -� ..Garbage Grinder.... -::-Lot Size.-....1 Public System and name.-_- ' "S t Character of soil to a depth of 3 feet: Sand ❑ ----- ......Private Silt Clay ❑ Peat ❑ Sandy Loam ClayLoam Hardpan El [] Fill Material_. ..- If yes, t �h (Plat plan, showing size .. ..... of lot, location'of system in relation to wells, buildings; etc, must be placed on reverse side.) NEW INSTALLATION: No "septic Tank or seepage " tpit-permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ) SEPTIC TANK Size-- ---------- ---- -------•------ Liquid Depth.--- Ca _cit // .._...... P Y--1. .01 TYpe '` 11r1aterial- # 44..:No. Compartments ..-••--.. ...... I Distance to nearest: Well..._..-� .0.--�- --- -----Foundation..... - " LEACHING LINE t �� Prop. L;ne_.._ - No. of Lines ._... ---------------Length of each line._..._- _ s ----•----,.-- Total Len .. ..e7Q (p s D' Box_ __...Type Filter Material. _ --_.Depth Filter Material- Ago _....... ..:-------- -- --- Distance•to nearest: Well-- rr_.... °`Foundation.---. Q- Z- SEEPAGE PIT A ---..--Property Line -. ----- " ) Depth._?. ..._Diameter..... -3.-------.Number_......A - f- ❑ " No ❑ Water Table Depth...- - 1.1 Rock Filled Yes *� �� Rock Size..... .:.��-... Distance to nearest: Well...................-... ' Foundation. .._.Prop. Line----... � . REPAWADDITION (Prey. Sanitation Permit#.......-- -° Septic Tank'(Specify Requirements)------ ---- Date........:....... - }� Disposal-Field ISp"ecity Requirements)__...:.�: ------- --- .---- � � \ _-•---•------- ...... -- -- - ------- --- ............... ------ - ---- .... t .(Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done.in accordance.ywith San Joaquin County E' Drdinances, State Laws, and Rules"and Regulations of the San .Joaquin local Health District. Home owner or licensed agents signature certifies the followiiig:' `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 o become su ject Wolk en's ppnsati laws of California." iigned.- __..__ - �.- •-------- .. --Owner 3Y-•..... ..... ................ . ------ -- •" Title--- (If other than owner) FOR DEPARTMENT USEONLY 1PPLICATION ACCEPTED B )IVISION OF LAND NUMBER...... DATE :...._ ------ w.- ...-- . ZI)ITIONAL COMMENTS........ o-LL, [ --. •..• -............ DATE... ----------- --- ... ......... ----.... --- I .-- .......I................ ........ E- ... ..._....-- r nal,Inspecflon b � -------------------------------------- ----- - -- --- ------Date. 13 243 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M