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#FOR OFFICE USE: "�. APPLICATION fOR SANITATION PERMIT FOR OFFICE USE: "r -= (Complete in Triplicate) i i Kermit No.... .".- --- f . This Permit Expires 1-Year From Date Issued Date Issued_- ------- Application --Application is hereby made to the San Joaquin Loco] Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: 7--T.-.-.r— _ .. JOB ADDRESS/LOCATION__=.-j _.- c- ---_ c �Y ,C = Owner's Name-: -- . UT"il/C�%1 :.- --------- ----------------- _4 y CENSUS TRACT r. one ----------------------- Address------------- - - Aor M p� ----------------- ---- = Zip City- -. 0f1 q�S!�� P - Contractor's Name_ ".-r-/ iYT ----- -�er - /�6 ' N ---- License #------- ----------- Installation'.will nsta ation::will serve: Residence ❑ Apartment House ElCommercial ❑ Trailer Court ❑ , I' • _ . . . ti - - ..:.� Motel ❑ . Other-- ti P*10_61,4 k/oowa _ _ _ - ---------------- Number __.-.__ - i Nur Pp Y g �y ; =------ --Lot Size-_. _�. f - g - - - ---------- tuber of"livin u.mts:.--,.__I-_"-___Number of.bedrooms_-.----___--Garbo a Grinder_ Water Su I Public 5 stem and name ____--- -_. ------------------- ---------4 •• ------ --------------------------------Private Character of soil to a depth of 3 feet: : Sand ❑ Silt �] Clay ❑ _ Peat 0 Sandy y Loom !Clay Loam .. ❑ Hardpan E) : Adobe 0 Fill Material._._-_.]_]_-If yes, *-fiype.._,_-- iP (Plot pian, showing size of lot, location of system in relation to'wells, buildings,'etc, musi be'placed on reverse side.) NEW INSTALLATION: (No septic tank"or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT-[ ] SEPTIC TANK r _ _ ------------ - ------- -- ------------------Liquid Depth------------------------- Capacity-_-.----------------=TYPe = :MaterialGo NG` :-No: Compartments------%` . .'Distdnce to nearest: Well------ oP�: ' € Foundation_ p. - ------ o LEACHING LINE [:1 No. :of Lines-' ---- _--- --- :Jength of.each fine p 1 hr iZ O '�S O r --�}zd ---------- I 'D' Box-.J-:."Type Filter Material- /?o-GSC --Depth Filter Material T met#gt ;-- Li - . .-a - --- ----- } A j .Distance to-Nearest: Well _ f<. SEEPAGE PIT [ ] bepth_ ; Y ' Foundation-- ------ -.------Diameter -� .."-- Number . ._-- -- -- --------------------- Rock Fi ------------ -_Property Li Water Table..Depth----------- ------ . :- Rock -Size------- ------------------------ is ante tb.nearest: W :-Foundation - ------------ ---- --.Prop. Line------------------------ REPAIR/ADDITION (Prev. San itation;Permit #---------------r-_ -:---- Date------- � e _ --"--._ _ i` ) Septic Tank (Specify,Requirerhents)=. ---_____;_______- - - ) i ----"---- `---- - Disposal Field (Specify Requirements) _-------- --- -______ ____ _____ -- ------------------------------------------------------------- ----------- -------------- =--------------- sl1 ---------------------------------------- : ------ ------ ----- ------- -------- 4 _ 5 --------- --------—- ----- -= ------ --- ------------------------- P (Draw exis ing and required addition ori reverse side) 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 Regulations' of the San Joaquin Local Health District. Home owner or licensed agents signature certifies,the following: ' "I certify that in the perfeemance,of1the work for which this permit is issued, I shell not employ any person in such mannerless to become subject to,Workman's_ Compensation". law .of California.' i P Signed N_� O//y __ r -- ----- Weer - l BY } i ------ - T . er than owner) { -.- 'FOR`DEPARTMEWT USE ONLY w 1• APPLICATION ACCEPTED 13Y---- ' 4 DIVISION OF LAND NUMBER_._"-..___.- .;._"- ----- --------------------------------------------------DATE.---------- ADDITIONAL COMMENTS---------------------------- - --------------------------------------------------------- - ------ ------ ---.------- ---- --------- ----------------- ------- --------------------------- ----------- -=------ ----- ------- -------- EFFinf Inspection by r -Date.- 13 24 - SAN JOAQUIN LOCAL HEALTH DISTRICT ` F&5 21677 REV. 7/76 3M ,