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e FOR OFFICE USE: FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT 3 fp--- ------------------------------------- ---------- (Complete in Triplicate) Permit No-173---- --------- ----------------- -------------------- - ------ Date Issued_-_.��'�l -----_-_------._ 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 work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. �.f� CENSUS TRACT JOB ADDRESS/LOCATION---------------- --- ------- - Phoe ------- - ----------V.6?._ Owners Name.--- - Zi --- j lY36-�- �[} s41�f2 Ci 1/21/00-t----------- ----------z1p ----------Address - ------ #------------------------------ one---------------------------------- Contractor -- ------ ---------- lsS -s5:-----�cJ _ --------------- Ph Contractor's Name__/__�----. --- _- Motel Other"_- 5e ❑ Commercial ❑ 'Tra'ler Court ❑ Installation will serve: Residence Apartment Hou �j ) E. .__Garbage Grinder____. -----Lot Size_,_ " Number of living units:----- . -----Number of bedrooms__ --------------------------------- - ------------ -- Private Water Supply: Public System and'name----_------------------- " Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ®' Clay Loam ❑ _.Hardpan ❑ I Adobe ❑ Fill Material------------If yes, type----------------------------- - [Plot plan, showing size of lot, location of sysfem 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,) , Size_ vC� Liquid Depth.. ------- ------- PACKAGE TREATMENT [ ] SEPTIC TANK [ A 4 Capacity/�U_------- Type — -Moterial -"-No. Compartments-___ ---------------- Distance to nearest: Well____________________ Foundation - ----Prop. Line--------------------------- - 11 • LEACHING LINE- [�.No. of Lines__._.____�r-„-_-, --Length of each.kina.____ZD-----------------.Total Length-�_.�' --------- ---------- -- a �r ” Yp `D' Box_. �_,__T a Filter Material 5,dPrK-" ----- . pth Filter Material__ S"- Property Line. - oU� t ---------- Distance to nearest: Well,, __�___._____--Foundation..-�--(0- ----------- p Y + Rock Filled Yes E] No ❑ SEEPAGE PIT [ ] Depth----------- ----Diameter------------.-------Number---------------------------- Water Table.Depth---------- ------=- -------------- Rock Size - = '` f Foundation---------------------.--- Prop. Line----------------------- -- .$ Distance to nearest: Well-------------------------------------------- E REPAIR/ADDITION {Prey:Sanitation- Permit#_._.___-_-------------------------- - Date --------------) + Septic Tank (Specify Requirements)_ - --- ----- --------------------------- --------------------------------------- . - 41 f ------------------------------- Disposal Field (Specify Requirements) - ----- _; " - ------------------ ----- -- -------- ---- -'"`------------------------------------------------------`------------ -- ------------ ------------------------------ (Draw existing and required addition on reverse side) e I hereby certify that I have prepared this application and that the-work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the 56-n Joaquin Local Health Dict. Home owner or licensed agents i signature certifies the following: - x "I certify that in the performance of the work for which this permit isissuto ed, I shall,noerr+ploy any person in such manner as F laws. of California.." �. Y� �' d o `� Owner Si nbed � subject Workman's Compen ion ----- -""- - S.jl -�--- -Title------- ----- -- ------- -�Y-- --------- --------------------------------- By --------------------------------------- If other than owner) Iv RD PARTMENT USE ONLY r F s ---------------- - DATE. ----- DATE Zs' 7 ------_----- APPLICATION ACCEPTED BY -.---------- --------- --------- ------ - DATE------- ----------------------- -----_ DIVISION OF LAND NUMBER ---------------------- - _,.. --------------------- ---------------------- ADDITIONAL COMMENTS..---------=---------------- 1 - ------------ ------------- -------- -- ---------------------- ---------------------------------------- -- ---------------- ---------------------=------------ ----------- - - ._ - ._- . w l_---------- -- ------ -- ` - ------------------------------------ = ------ -------- ------------- - - --- -----I---- _. :. ----Date'--'�---�- � --- -- ------- --- Final,Inspection•b — y°'""""-`�'---------'�=�----- - �----- -- -- - -- F85 21677 REV. 7/76 3M EH 13 24 SAN JOAQUIN LO AL HEALTH DISTRICT