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r FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: (Corr4lete in Triplicate) ,¢ Permit Date issued-."// - This Permit Expires 1 Year From Date lssued Application is herebymade to the San Joaquin Local Health District for a permitoo construct and install the--work here n.described. This application its maadde.-in comp!-ian e-with County&cl-inance No.f549 andeexi•sting Rules and'Regulations: i i JOB ADDRESS/LOCATION_-.-- - - ��v /4cf i i ------- -� ------------ - --------------s---------.0 CENSUS TRACT �a Owner's Name - ✓ : „` 0-.�� -- -Phone � � I Address -- - } ..... r i - .. r � ty�-, -�.• Zip Contractors r '� _ I; = s ---,3 5 22V -Phone---s License # Com'- ; ,i .. : �. Ir�'stallation will serve: Residence ]! Apartment House{❑ Commercial 0 ;Trailer Cab rt� , �� .. ..,Motel ❑ ' Other. - Nu`mber of living units:_ Nf __ __ umbe�riof.bedr orrms .- 'Garbage Grinder ._.,,L.____ _Lot Sizes__ Le Water Supply: Public System nd nae-- '- .., , s j ; '.. �`------------ ---------------------------Private 44/ Character of soil to a depth of 3 feet: Sand [Silt Clay ❑ Peat❑Sandy Lo&n k]�Clay Loam ❑ ' Hardpan ❑ : Adobe ❑ 'Fill Material--_F .._!f yes, type_ _-" _--'.- --r`---_ (Plot plan, showing size of lot, location of system in relation Alls, bindings, etc-.must be`placed on reverse side.) NEW INSTALLATION: (No'septic�f&nk°or seepage"pif permittedrif public sewer is available within 200 feet,) 1 PACKAGE TREATMENT [ ] SEPTIC TANK - . - ..-----Liquid Depth - ------ ---- ---------- Capacityt YP No. Compartments--.---__*___ f k --------==- -----T e.-----=-----=-- Material-- '--- -- --�---=-�-- --- -- [ � Distance.to nearest: Welly�' = Foundation _ P [ `ILeng.th of each line--- ------------------------- Total Length ro ------------- -------- 'D' LEACHING LINE [ ] No. of Li'nes___________ _/, _., j 'D' Box ___----Type Filter'Material'_ _ ` u i A -- Property L• ._--_ _Depth Filter Mate nal------------- Distance to nearest Well f__-. _Foundation SEEPAGE PIT [ ] Depth-- --: _Diameter Number ' _ --- - Rock Filled Yes ❑ No ❑l _1 ,;Water Tabie;Depth ----- - _- Rock Size_r..- / -r• A Ib f - , - ;. t Distaneo nearest: Well-- ----- --=--------------------- Foundations `--- `_.Prop, 'Line-__ -- --_ t EPAIR/ADDITION (Prev. Sanitation Permit#_______ _ __________ - Date- ----------- �•• ) - = ------ Septic Tank (Specify Requirements) =------ ---- ------_--- -�;t - ------------- ------- Disposal Field (Spe4ify Requ.irements) ------ - -Lc��1.. _. i.�,�.� 'f+r' ' 1 uJ c _ }�-- ------------ - �. -----------------'--------------- I (Draw existing and requ�ed addit�onyon reverse side) I hereby certify that l ha a prepcired this application and that the work will be-done in accordance with San Joaquin County Ordinances, State l;'aws, and;Rules I and Regulations of the- Sun Joaquin Local Health District. Hom_a owner or licensed agents •i signature certifies the following:` `' "I certify that in the performance of the work for which this permit is issued;&shall,not,emplly.any person in such manner as to become subject ;to Workman's Compensation laws of. California.". f Signed-- ---- = -- Owner BY--------. - --------- --------- ----- Title � �-----`--- --.------ -� --- 0f ethe—rt Fa'n owner) F ; FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY x a _ DATES! -;�" ,� = DIVISION OF LAND NUMBER-----__; : =:.: - DATE ___ ADDITIONAL COMMENTS-------- ----.----------- --------------- ------- ------------ ------------- `------------= ` ---------------------------- ---------------------------- -- --- -- s --- ------------ ---------------------=----------- ---------------------- -. ------------------------=----------- - z Final Inspection by _ - ._....:..,.,-._ _.... . Date-�� /72--- = ---- �Hd3 24 S N JOAQUIN LOCAL HEALTH,b.1STRICT F&s 21677 RM 7/76 Sen d