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FOR OFFICE USE: " APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: (Complete in Tri licate) Permit No,79: d v�— This Permit Expires 1 Year From Date Issued Date Application is hereby made to the San Joaquin Local 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: JOB ADDF:ESS/LOCATION _ I- -- .__/_ D/�------ 1 CENSUS TRAC - �._ Owner's Nome --- u U ----- ...---- -... f -- ---- -- �._ �? r w Pone _ �3$ / ----------- ------------- Address 1-D. ..f- T �/_P!r�-- -N . . ----------------- ---------------------- ... City TUL'f�`f¢N - - Contractor's Name._ .. __ n -----—Zip-=--- - ---- ---- ------- ti c...G+-4,-.. -- .License Installation will serve: Residence Apartment House [] Commercial ❑ Trailer Court ❑ ��r Motel [] Other----------------- Number of living units:.----- -------Number of bedrooms _-_Garbage Grinder-.-.. Size �5-- : 17-f_ ---- Water Supply: Public System and name_- -- ---- -- - -- - - --- -- - - ----------Sa--------y----- - Character of soil to a depth of 3 feet; Sand ❑ 5ilt❑ Cl--ay-- -----❑ Peat-El ndLoam ❑ Clay Loam Private Hardpan E] Adobe'❑ Fill Material-- ----..-.-If yes, type-------------------------------- jPlot 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 pit permitted if public sewer is available within 200 feet,♦ PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------/,V/-D_Q--- L------------------------Liquid Depth.---- ------------------ Capocity----��0...Type-----------------------Material- No. ompartments..---�- --------- ------- Distance to nearest: Well__ _ p_b__�___.. -------- Prop. Line... LEACHING LINE [ ] No. of Lines-..... T g o f. f p ` rg Length of each line-------- ----_----__ .-.Total Length -- 0.0 'D' Box-......._.__Type Filter-Material_ �_. �QC/�'pe h Filter Material_____ . _ ___----------------------------- Distance _-Distance to nearest: Well..._��4..-`. .._ ` __FOUndatl n___ _-.---- ---- Property Line.._Q__. _ i SEEPAGE PIT [ ] Depth..._-----------Diameter---------------- - r---------- ------- --_------ Rock Filled Yes ❑ No Water Table Depth.--<------------ ------- ` — Roc Size ---------------------------------- Distance to nearest: Well------- ------------------------ -___F undation---.--______-._.___ ----- ---.Prop. Line-------------------------- REPAIR/ADDITION (Prev. Sanitation Pe it#------- ------ - ------ -------- - ---- ---- Date-- --- ---------- Septic Tank (Specify Requirements)---- ---- isposal Field (Specify Requirements)_-..____-..__._ ---- ---- -------- ----------- ----------- -- ----- ----------------------------------------- -- ------ ------------------------------------- IDrow existing an quired addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin r Ordinances, State Laws, and Rules and Regulations off the San Joaquin Local Health District, Home owner or licensed signature certifies the following: f "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manne to becoiubject to Wo krnan's Comp%ns t' laws of California." Owner Signed-m �'- G�= Y-- ----------------------------------------------- --------------- ---- - other than owner) -----------------------------Titte-- ------ - .. ------ ------ -- w FOR DEPARTMENT USE ONLY + APPLICATION ACCEPTED BY___._ - ---- i ---- ----------- -------------- DATE _1/--.. - DIVISION OF: LAND NUMBER .................._- ----- ------ ------------- DATE -------- DITIONAL COMMENTS F -------------------- ----------•---------------------------.----------------------------------------------- ---------------------------------------- --------- ------- --------`----------_____-_._._._______ -___..._. Final Inspection b - --------------- - - ----------- --- ---- --------------- ----------- --------- ------------- --- PY +---- a ---------------------------------------------------Date Eli 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV.