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ak .r :FOR OFFICE`USE: rr57 ?.„j< :.;� sry,y+r i•. �.g'a+'rtr7';!.i �t`�'x - r7z+r. .sa«.i”` n' t1+a Fs 1 , ` APPLICATION FOR SANITATION'PERMIT f FOR OFFICE USEi �J�"' (Complete in in Triplicate) Permit No., $'r.lp:�.b < ......... �... T .. 2. .. ..... ................ .....---- .•... This Permit Expires I Year From Date Issued Date Issued..S�_�r..ZS� Application is hereby made to the Son 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 ADDRESS/LOCATION.1�..,0...O...� Owner's Name.-.. ...._...-._..`.._. s Q _.'..... ......9. ...Q....-.-.....................................................CENSUS TRACT............. .........-...... _ y - ............ Address Phone. s�... ... . rry/. -Zip. s36. ........... Contractor's Name...-...... ,1 a .-....-..... - ... _ _.. .....License #......7-_�...%.... .Phone..._...... - -.. .._-.-.... Installation will serve: Residence Q Apartment House E Commercial ❑ Trailer Court ❑ Number of living units- Motel ❑ Other.... . .... ----------------Number of bedrooms........_. Garbage Grinder...._.- ...Lot Size--.li( Water Supply: Public System and name.._.... -- .-................................ .................... . .. :.Private�' Character of soil to a depth of 3 feet: Sand cDSilt❑ Clay❑- Peat❑Sandy Loam Q " Clay Loam E]Hardpan El Ado e Q Fill Material.. ......._If es, (Plot 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 I"Public sewer i} avail le within 200 feet,) V PACKAGE TREATMENT [ ] SEPTIC TANK /K ' Size .7...�-1,�-�� ,� ------Liquid Depth.....7.....__......__� Copocity�-yw....._Type-17.0-� � MateriolS-.aX!.^.G!----„•No. Compartments.--.-..-.-_�_"�. Distance to nearest: Well.:. . ....t........ ... .....Foundation.. . Line....-.......l -- LEACHING LINE [4-�No. of Lines . ..., // r / r ...............Length of each line.f�.d-.-l0-.0-.. �_._Total Length -._ 8 D' Box.v.._Type Filter Material.%5l./C.QG/.Depth Filter Material...... cj�..��................ ....._ Distance to n EEeA ' f r earest: Well-/C�.O---------------Foundation..,100A0.................Property Line S .. T Is'r Depth.-./.O, Diamete ...C2��Y�©..Number.._....24. ................ I/ ' Rock Filled Yes 2?'—NoWater Table Depth.. ---------c/d-....................................Rock Size.. Distance to nearest: Well/OO-.......!!!7......._------Foundation......1"4....-_.......Prop. Line.... .-... r REPAIR/ADDITION (Prev. Sanitation Permit#................................ _. ...............Date--- ....................- c .iepfic Tank (Specify Requirements).__. ............. Disposal Field (Specify Requirements)..................... ............................------------................................................................ .....................•_.................... (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 San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents signature certifies 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 beco a b[ cf fo Wo I Eads ompensation laws of California.” Signed-.-.- .... . --- --- Owner E By................. ...................... P- ... - Title........... Y-........_.. (If other than owner) _ ..................... ......... F PA MENT 5 NLY APPLICATION ACCEPTED BY.............. _... .. . ----- ...............DATE ..._.. .: DIVISION OF LAND NUMBER_..._......__ .......... � ._ _.. _.. ... .............. . ............. ........... ............ DATE...-_... ..... ... ..- .......-- . . ADDITIONAL COMMENTS........... ........... ... .._.................. .....------- .... - .........-------------.................................... ....-_._....................................................__. .._. ............. .................._.._--.---_....... .. _.............— ----:.................-................. .. ._.... ... -- ` _.................. :final Inspection by:.... . . ..... . .. j� .. . ... ... !' .. . .-_. -- . ...._.......-----Date..... :x is z. -.-/.D,......_-..__....... SAN AgUIN LOCAL HEALTH DISTRICT „mss 21W REV. 7171