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S R OFFICE USE: FOR OFFICE USE: , ` APPLICATION FOR SANITATION PERMIT --------------------------- -------------- Permit No tete in Triplicate) ----- -- --- - -------- -- p P f -- -: .� Date Issued__o�_'_��_�� --__-_________________________--.______- _____ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wor-k_herein described. L This application-.is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: • JOB ADDRESS/LOCATION ® a l_4 Q' ---- -- - ----` ----- TRACT � _ US Owner's Name------ --- ---------------------- 7 _ `___.CENSUS ' q Imo , ,, p� _�. _: Address_._ C�%� ------------C -- --- -- City iP --------------------- - / Z �Zy �j, Contractor's Name - �� __ -- - -'License #. 1 _ f--Phone Installation will,serve: Residence [ Apartment,House ❑ commercial` --Trailer Cour ❑ cd Al Motel T Other , " t Nu`mber.of living units: [ Number 'of bedrooms_'_ Garbage Grinder. _Lot`Sie ____ ,_ ______ --- ---- Water Supply: Public System gndname -- - °- :- --: ------ --- ----- ----- ------ --------Private ❑�, Character of soil.to a depth of 3 feet: = Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ] Clay Loam 0 ? �' r Hardpan ❑ : Adobe Z Fill-ateriaL_ __-_If yes, type______ d' 3 � i (PlotIan, showing size of lot, location of system in relation to;'wells, buildings :etc."must be placed on�reJerse'side.) P 9 t i NEW INSTALLATION: t(No,septic tpnk or seepage pit permtted¢if public sewer is available within 200 feet,) i j t -_''_'.Li uid De tli _ PACKAGE TREATMENT' [-]—.-SEPTIC TANK [ ] Size_ s. ;q Pj -- --- ' Capacity =---!Type '_ =_ _ Material - -___ =- _ No. 'Compartments �`_-'_ ( f -- I I Distance to.n arest: Well Foundation €_ B __ ___11Pro Line_ 3s LINE__. [_] No of Lines_ Length of�each lira `_ ��__ Total (Length..------------- LEACHING � � 3 i D' Box ___ Type Filter Material Depth Filtr IVaatenal f Distance to nearest Well FoundatioProperty Line f - SEEPAGE -PIT [ ] Depth Diameter__".,_.----�---- .Number __ i Rik Filled Yes ❑, No ❑ 1. Water Table Depth', r" Rock Size' l-. --- '--- 4 Distancetonearest: W,ell _ :___ _ Foundation C ' __ .4Prop. Line_ ----------------- _. i i REPAIR/ADDITION (Prey`Banitcti$n,Permit:# -�.;�. `--------------------------- �' aDa#e ___. _- _ Septic Tank (Specify Requitem s')`�*`` l_; :t .. « ;_...... _ --- --------------- Field(Specify Requirements) _- � - --`4�%/A�- ---- � ---------- ---------------4 �`� -------------------------- Disposalr i r y ' - - _ 4 ; .``1c:Z- - --------------------------------------------------- S_ r , - j :-- � ,j,� w y --fe __:F l (Draw existing and required addition on reverse side) , hereby certify that [ have prepared this application and thatth;e.`�work will be d'ohe'in accordance with- San Joaquin County ,.. Orgdigta'ces, Statelaws:, dnd' Rules and Regulations of the San Joaquin Local HealthDislfnct, Home owner or licensed agents e certifies the following , s "I certify that in the performance of the wiiork"for viihich'th�s permit is issued ) shall notEe ploy�any person Vin,such manner as w _ - ( to become subject to Workman's-'CompensationFlaws_of California"_ Signed_ ; -------- -- -O -- ---- --- ---- - -- -- --- Winer �-- i - _ , By ��. i Title I i (If other than owner) ` FOR' EPARTM6f-i USE ONLY; , APPLICATION ACCEPTED BY r v z=' - - -- ==# = '_-- :_-; D`ATE � 4 TE DIVISION OF LAND NUMBER ---- ---- ---- - DA - 7_ i ADDITIONAL COMMENTS --- -- ------------------- -- -- -- -- - -- -- -- --- _... , --- ----- - - -- ------- ----------------- ------------------------------------ . - -' -: a l <--------------------------------- - - " -- _- - Einal Inspection bY -__ '.24 SA JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3m