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FOR OFFICE USE: I FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No.. �. ... ........ Date Issued. 7-- 7 ..._ ___.. ...-. _. 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. his application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: L JOB ADDRESS/LOCATION .2 3 _3�-....5_--- 1�^ k.___ - .........................CENSUS TRACT ---------------------- Owner's - - ..... Owner's Name---.�/?o.!ft.. .G...... ry --- ---------------- ------------------ --------------------------------Phone.Sf'�-�----- y1S�,---- _ �y // / r� JJ tQf/ a � 1 -- city ` _._._.._Zlp._.._.._..__-_-TT___.--. ddress-------�.3?� � S �' r �r_ .. - - Contractor's Name. ----------------------.._--License #.xS-SL .4q-3-3- -Phone --------------- L ristallation . _-j. --Phone- -------_--------------Lnstallation will ser e: Resi ce ❑ Apartment House ❑ Commercial Trailer Court ❑ n L Motel rl Number of Iivin u -------- is;------ _N ber o bedrooms edrooms---------`t bage G�der---- -- - - - ------Lot Size----- -- - --- ----------------- ------------------- ;ater Supply: Publi System and aine---------------- ......... ----------------------------------------------- ------------- ------------------------------------Private Character of soi to depth of 3 f t Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam E]L Hardpan Adobe Fill Material______If yes,type-------_--- - -_(Plot plan, shov,Ing 5ize of lot, Icc T n of system in relation to wells, buildings, etc. must be placed on reverse side.) LNEW INSTALLA 10 (No septi, ankle-seepage pit rmif#e ublic sewer is available within 200 feet,) I 6 -1ACKAGE TREA ME T [ ) SEPI TA K Size-- ------ - ------- _Liqui ep - - Capacity--[ ----- -----Type--------------. .Mater al 9brt eAlr..No. Compartments----------�.- ------ ------ -- Distance to ear ist: Well ------ ---...__-.... ..... -Foundation._-_---._-._______Prop. Line.._.____..........___ EACHING LINE No. of L' _. __/--------------- of each Ii e._ __----._---------------Total Length---------_QCT_._._._.--.-._ D Bo&- > _ a Filter Material-------------------- ept Filter Material._ ...._---.-._-_.--.......-._.-----.--___------------- L Distar �o Oe r st: Well---- 7'..-..Foun ati n..... . ......._...._.Property Line___./ SEEPAGE PIT [ ] Depth�a. r. umber Rock______.___�- ._yy. Rock Filled Yes ❑ No ❑A Water tfable De th - ------------------------------ Rot1c z - - - - L Distance to near sT: Well _---------... --- earc < Fouri n �U - �----------------------Prop. Line------------....----------- -REPAIR/ADDITIBN ( rev. Sanitation Perm t#-. ------------------- ..... .._1.Date.-. .Q.....-.-._------------------_-.) L4eptic Tank (*ecify)1quirements)---------- ------.------------------ ---------------- -- f ------ ------ DisposalField (Specify --------------- ------ - -------------- ----- ---------------------------------------------------------------------_- L ro -- -------- --- ---- ------------------ - - - - - ------------------- -- ---- ------------ - -- - -- -rte- - -- - -- ------ - - - - (Draw existing an�(quired add i n on reverse side) hereby certify that I have prepared this application and f at the war uin County rdinances, StateiN and Regulations of the San Jo quin Local Health District. Home owner orlicensed agents signature certifi LI certify th ce of the work for which this permit i issued, I shall not employ any person in such mann& as a becom sub 1' Co nsatioa laws of California.' Signed .. . Ow ar -- -- ----- L3y - --- -- Titl _------- --- than ow er) FOR DEPA dA-Ekl E Y `4PPLICATION A CCETED BY-------------------- --- --------------- ------------ -----DATE.---- -..'/.c�1" -......__..-- - DIVISION OF D UMBER- ---- --- ------------- DATE.-------... - - - ------------------ ------- -------------- -------- --- - LADDITIONAL C M ENTS------------------------- --------------- ---------------------..__.__.. ---------- ------- -- I -- - - --- -- - -- ----- - --------------- - _ . -- --- ------------- -- ---------- - .. ------- ------ --------- -------- -- --- =final Inspection by.- ------------------------------- - AJ11t/date-... ��•f- S-------------------- 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F83 21677 REV.7/76 3M