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a. .. - R UrrK t USE: ` -- APPLICATION FOR SANITATION PERMIT ----•- 11—.. �.................. --- {Complete in Triplicate) Perm�it No. ..� — ........... •- This Permit Expires I Year From Date Issued Date Issuedx.;76 Application is hereby made to the San Joaquin local Health District for a described. This application is made in compliance with County Ordinance Namit 549 and to nexlsting Rules and tanthe d ReguleIonsrein JOB ADDRESS/IOC N ._...._.._I-._... Owner's Name ...-- ��''p�-•-""" ........CENSUS TRACT .._....... Addres ............ ..............Phos s ... ..... .... . . ..1D7 a ............. ....._......._... Contractor's Name # ....... city ............ . ._r. r P .._._ License . .d�rt�. ! Phone .................. Installation will serve: - -••••�-' Residence artment HouseO Commercial-❑Traller Court ❑ 10. Motel ❑Other-,........ Number of living units:..... Number of bedrooms .y.....Garbage Grinder ...__. .... Lot Size Water Supply: Public System and name .. ....................Character soila depth of 3 #eet: Sand b Silt Cla ❑ Y ❑ Peat❑ Sandy loam UT0, Clay Loam ❑ f Hardpan❑ Adobe fl Pill Materiof ............ If yes,type (Plot plan, showing size of lot;-lo9Wtion of system in relation to wells, buildi {Na septic tank o NEW INSTALLATION; o —_ ngs, etc. must be placed on reverse side.) r seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ( ] SEPTIC TANK 1 ] Size........ ............................. Liquid Depth Capacity -------------------- Type --------••-----•---- Material-----------------• --- .NoCompartments p Distance to nearest: Well ____...--• _-- . .._... ---••---•---- Foundation ............. Prop. line ........ LEACHING LINE [ ] No. of lines --__- Length of each line.__ ` •�•� ------- --•-•- Total Length N i _.._.....- 'D' Box ..__E.-----. T g ............................ Type Filter-Material ....................Depth .Filter Material F Distance to nearest: Wel! ------------------------ ......._... ••--........--.... SEEPAGE PIT Foundation -. Property line _...__.,__,_,•, ) Depth ..•.... ............ .Diameter Number .__. .. ---.---•• ..... Rock Filled Yes ❑ No ��5:Water Table Depth -.----__-.-- .-- _ . •........Rack Size ----••----- - .._...._._ Distance to Nearest: Well __.._..-----•-•-_---•-•----_••-------.._Foundation .............. , REPAIR/ADDITION(Prev. Sanitation Permit# ...:.............. ...... Prop. Line .._...I....._._.--•-_- ............. Date i Septic Tank lS ecif Requirements') sposal FieldS ecif Requirements) ° _-- '-� •---.._....."---'-••. ......__...•""" # P Y q Ale- -----------.1_�r�� , f ��caa (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin....................... ......... County Ordinances, State Laws, and:Rules and Regulations of sed agents signature cethe San Joaquin Local Health_District. Florae owner or iicen- � rtifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person In such manner as to become subject to Workman's Compensation laws of California." Signed ----•--------•- 6._ 2- --- ------------------- FOR.DARTMEI+IT USE ONLY APPLICATION ACCEPTED BY -------. .-- � ��_- -- - BUILDING PERMIT ISSUED ----- DATE,. ADDITIONAL COMMENTS ..----- .�.. _ --•----• -------:;- --------------- ------ . 'r -�� -- ..------------------•- --•-•--------,-----Gy---- - --•------..._-----• ------•--•-----�... ..........DATE _... final Inspection by: ............................. _._------••--•- -- -- -- --•--• EH12 Date ...... .—..� SAN JOAQUIN LOCAL HEALTH DISTRICT 8/71; 3M