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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: _ F. (Complete in Triplicate) Permit No._2 7-_7 OP -- ------------------------- -------- p --- - >�'.�a-J7 __.This Permit Expires 1 Year From Date Issued Date Issued--,0-72<1-,,;1',7 is hereby made to the S n'Joaquin LocalrHealthDistrict{or a permit_to construct;pnd install thew 3W F permit to r. r j,:—n This application is made in compliance with C unt Ordinance No. 549 and existing Rules and Regulations: work herein described. �.v JOB ADDRESS/LOCATION ` f ! Owner's Name-- - CT--O__. . � � TRA �[-- ---- ----- -- -- CENSUS Phone " + Address-----'- ---, -----��- -`/'� - .�. . '---- ----" -- Ci r Contractor's Name. -_^ _4 ,,' ` tY' ------------= Z ' ` Installation will serve: License S C—*_ - _O Motel p i Phone .! �4 Residence A artment House.❑ Commerc+al ❑ Trailer Court ❑ V . ; .... t� j I t ❑ Other ----= -- _ .. _____ __ t Number of living units___ _ _____Number of bedrooms:_.__ f - r _:_--Garbage Grinder_- -- Lot Size_ jf Water Su 1 Public System and'ndme _-__-: �_-� 7 ` - PP Y r C i x, ----------------------------- Private -- Character of soil to a depth of 3 feet:'- Sand s � ❑ Silt❑ Clay ❑ : Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hard an ❑ F+I! Material-- ... . if Yes, type--- ------- ---------------Clay❑ 1 Adobe (Plot plan, showing size of lot, location of system' in relation to wells, buildings,.etc.,rnust be laced on r NEW INSTALLATION:` p reverse side.) 'IN tank or seepage pit permittedif ublic sewer is available withiri 200 feet,) 6 PACKAGE TREATMEiVTx [i] SEPTIC.TANK f�({� yq Size_- ' -`LJ L+qu+d Depth.-----,-, trh . - CapacitType- Vaterial� •-Size-- ------- partments_____Distance o nearest: Well `_ - t LEACHING LINE "- ---------------- p• ----- LINE of Lines%, t'_ lin e$,� ; ; -------------�--.:Length of each i s #Fo ' un - .i l - Prop. th otal Le D' Box -- ' --Type Filter Materia_- �r1 - -Depth Filter Material-- ----------------------- Distance to nearest: Well- ------ t �-Foundation_._} � y ---- ///• SEEPAGE PIT;• Depth.. Diameter_r roperty tine # Water Table'Depth_, - _�_y - 7 Y Fif,ed Ye No Rock s� Rock -- ----- Distance;to nearest: We11-___________________ REPAIR/ADDITION (Prev, Sanitation Permit#---.__ Foundation___--_-- --_ ___ -_.*_.prop• Line._______-_---- - - - � ,Date- ------= ----- - - � --- ------------------ - Septic Tank (Specify Requirements)_- -------- - ---- . -------------------------- - Disposal Field (Specify Requirements)-------------------- f r r - - --------------!..------------------------------------------------ -------------- - x ! . -------_ - -------------------------- ' I r_---------Z- - ----- ----- - ---------------- - ° (Draw existing and required addition on reverse side) --•--- - ------------------------- i I hereby certify that 1 have prepared this application and that'the work will be done in accordance with San Joa uin 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 i ' performance of the-work-for which this •permit is'issued, I shall not erriploy.any,person in such'manner as to beco a subject .to Workman's Compensat' Ipws. of California." Signed--- 1-L + i 4 s - - -------- .- r - ----' - -------- By-. ------- - ----------------------- - a {]///yj,/, ----._Title f r-. - I -------------- Title.- (if _ ' µ (If other than'owner) -' ---' € }' FOR DEPARTMENT USE ONLY 17 APPLICATION ACCEPTED BY____ - DIVISION OF LAND NUMBER.------------------- -- - ----------------- DATE. ---- ------- --------- ------------ --------------- .-- --.----.-.DATE--------' .............................�.. t ADDITIONAL COMMENTS--'--------- ------- - -'__-' = ------------------•- -------------- ----------- --=---- ------------ ---------------------- -- --- Final Inspection by:. _ -- -----------Date - - = _t SAN l �y EH Y3 24 --- �C.� J AQUIN LOCAL HEALTH DISTRICT iVVV/ / F85 21677 REV. 7/76 3M a