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FOR OFFICE u�o: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit L -•---- . ............. ~-- (Complete in Triplicate) /7_7�---�-�• Date Issu �_---- --- ................... --.. .....-- This Permit Expires l Year From Date Issued __ ••��•• • : permit to construct and.install the work herein described. ' Application is hereby made to thBanca withuin CountyLocal OrdintancesNo. 549 and existing Rules and Regulations; This application is made in comp i _ - ........-------- ----•------•- �---�....-.CENSUS TRACT--- ---•-•----=--.... --- JOB ADDRESS/LOCATION..--....j_Z � Q �.... .�i.�.�f-.-� ' Phone_��' ..«_..._... = Zip ; 5713-6-. -•-.. Owner's Name_._... - e SSE_..... .0.1� a ------ _..City. ° c .7s42_ .G P ne Address.._�G9..44....�-.�'-}-'-�'a�--,-- o -------: . • . ..-�-- .License #..--•............... . � - Contractor's Name...--- � - C�mm ia1 ❑ Trailer Court ❑ Residence ❑ Apartment House Ll ejr installation will serve: 4.� - Motel ❑ Other.... . ,. ,. Garbage Grinder------------Lot Size._ ... -P � t A .... -- Number of living units:..-- Number of bedrooms: --....Private, ---- .... Water Supply: Public System and name----- ............ ---- Peat ❑ Sandy Loam ❑ Clay Loam ❑ of soil to a ep th of 3 feet: Sand [ Silt❑ Clay ❑ Fit! Material.. :-- - ..tf yes, type----------------------- Character --- Hardpan ❑ Adobe ❑ {Plot plan,showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) it permitted if public sewer is available within 200 feet,} t �� NEW INSTALLA .iCtN; (No septic tank or seepage p P --- ----------Liquid Depth------ - Size .._.. ... /-�aas ...- k SEPTIC TANK p prop. �-------- �--- - __V1 PACKAGETREATMENT [ 1 ��f Material. 4 �'�` -No. Com artments..-..... P A dC1 TYPe� Total Length .. . Lin -��--i - Ca perty-.'� Distance to nearest: Well.............. 0 Foundation Len th of ach lin LEACHING LINE l 1 No. of Lines .-------------s� g rc .r_. pth Filter Mat Material. D' Box. ....Type Filter Mater+al.,�P Property Line-------------- Distance to nearest: Well----->, �- -.Foundation-----,- Rock Filled Yes ❑ No❑ Diameter. Number_.. ------ SE�P �TeQepih r -I- . --�----•-•---.Rock Size------ 44 ---------- ------ --------- ----•..... 2 Q-.._...- -.. Foundation.-..------ Prop. Line Water Table Depth---------{�aT Distance to nearest: Well---------•-- - --- -- - ---�-.......Date.-------�---- --- ... ---------------- REPAIR/ --- ---- --- -�-- --) REPAIR/ADDITION (Prev. Sanitation, erml ----- -•--•- �....-----�- ---- ----------------- --•--...... Septic Tank (Specify Requirements)..---- ...._.. Disposal Field (Specify Requirements)...- ..... - - � - Draw existing and required addition on reverse s1 I hereby certify that I have prepared this application and that the 'work will be done in accordance with San Joaquin Countt Ordinances, State Laws, and Rules and Regulations of the San, Joaquin Local Health District. Home owner or licensed agent Ordi , rsignature certifies the following: . la any person in such manner a "I certify that in the performance of the work for which this permit is issued, t shat not emp sy to becom su ject fo W m s compensation laws of California." Owner Signe I -- ---� �---: .Title ---- -------------- - ------------------- ---------- .-- (if other than owner) i F RD PARTME USE ONLY DATE .........:./ APPLICATION ACCEPTED BY- • --.... ....-•-- DAT . . .... DIVISION OF LAND NUMBER.--------.-- .............. ApDIT10NAL COMMENTS ..-.- .--- -- - - --- ----- ------ �q a ----------- ---•Y -------- .....- - Date .. . 2 }Y'.. C/ - - - F&S 21677 RFV. 1174 Final Inspection by:----.- - -- - - ......... ... SAN JOAQUIN LOCAL HEALTH DISTRICT EH 13 24