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`FOR OFFICE USE: ---- -.. ""--__._ APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: ---------------- (Complete in Triplicate) Permit No...7r-- -�� __ - ---.------- This Permit Expires] Year From Date Issued Date Issueal_ F 7V, Application is hereby made to the San Joaquin Local Health District for permit to construct an This application is made in compliance with County Ordinance No`549 and existing Rules and Regulations: '.--�••--•�•--.�, �.,. ._„ .�„ ,,, d install the work herein described. JOB ADDRESS/LOCATIO -.-- .-_ _ ns: - ' -------- ---- ------- - - � CENSUS TRACTOwner's Namer. E - Address�TC ' � '.. ----- ----Pho Phone--- _A4 -rT. a e ' ' City_�� Contractor's Name._ t�f t _ — ' } / I ----- - v - '. �_� r License9--- Phone- Motel hon zip---- - 5 - - lnstallation will sjerve: ' t �. ...: .f Residence p w. _ e a _.. �A art Other--- House.❑ Commercial ❑ Trailer Court 0 ' Motel Other '------------__._. Number of living units:_'.. -.-- _Number of bedrooms__---_ ; F Garbage Grinder__:__._.__" Lot Size._._ 4 Water Supply; Public Sy..stem'and name - Character of soil to a depth of 3 feet: ; Sand �e,', Pe ------------------ - " - " - .--- Pr r ❑Siat❑ 5andy Loam ivatHardpan Adobe _ ` Cla Lop ❑ ._if yes, type- ---------- y m �. (Plot plan, showing size of lot, • s locas tion of-sytstem ii-relatonto wells,�buildings,RL-e4tc.°m; u.s.t:.be p.µla_ced.on•rerv:e_rse-sid e.)NWINSTALLATION: "(No€septictankoseep- age Pit permitted if public sewer is availaPACKAGE TREATMENT '� SEPTICTANK ble within 200 feet)Size }' i >. - al - - - - - �� ? Capacity-- _ _ -----_---Type..- Materi �lr - s -Liquid'Depth __i----------------------- --Material I •L i } = No, Compartments :_ - i to nearest: Well .- ------------- ----------- ------ LEACHING LINE, [ N o{'Lines- " ndati e = = f i t�-'�-, " -- Lengfh�of each lin`s. -Fu"----- -- -- - ----Tot - - - Foundation- LEACHING i. Prop L'ne- .'. 'i ' - - = 4 a1 Length ° - ----------------------------- ------ " I �.D fox -- T �} s :--Type Filter Material ----------------- Depth Filter Material- -.- f DiancEs to nearest: Well---- - ------- _ - --T, _Foundation SEEPAGE PIT [ ] �s CDepth .. - - -- D.iameter- -��. --- Number #pe¢ty Line- . Rd'`& Fill --- -P r � D'rstani`ea of n Depth _ . �__� _ ' _� :- _--- -- i ed . Yes' I y - C _----------- - ---- - N _ ❑ o j Foundati f t Ro k Size_ -( - ) _ii. --; crest. Well---- --=-- ----- -- ' ------'----- , on--` ----� . . � �� REPAIR/ADDITION (Prev:Sanitation Per ms `� ""'D"` -"- r e mit#_- == _ ------ ate .t--- Septic Tank (Specify Requirements) ;IZIA ` `'� '"� ' - y � --- "- -- --- bisposal Feld (Specfy^Requirements)-- ---- - --�.P� { -- --' - - - ----�---- :yam_. . ----'- - ------ ------ ------ ; g q --------- --------- -- - Y hereby certify that ( have re erred this application and that the work w}on reverse side) "`-'"' raw existin and re wired-addition ----------------------------------- I -�-- p p pp ; _ t Ordinances, State Laws, and Rules and Regula_ :tions of the. San Joaquin Local Health District. Home owner or lice Il be done in accordance with -San Joaquin County signature certi#ies the following; ' - used agents "I certify that in the performance of:the work for`wliich this permit is issued, .I shall not eni to an to beco u ct to..Worknta 's. Com nscition;laws of California."„ „ ,” person in such manner as" Signed ---- ----- Y BY-1 ------ - :. -Owner - ---------------- m - -----.-- - Title (if ot- er t . .. ---------------------F n owner)..;- - E FOR DEPARTMENT USE-ONLY;' L I APPLICATION ACCEPTED BY-=.__ - ------ --- ---- DIVISION OF LAND NUMBER. " = :::'' - =" ADDITIONAL COMMENTS------------- ---------- - ::-.DATE--! -- 1 ----- -- ----_-_--' --- --------------------------------- - -------- -- i : = - -------------------------------- Final•-n --- --- ............................................ spection'b �� ------ --- Y ' ' ---- iN 13 24 - , - ------.:_:Dater_- :'-/.i.-_�8.------_------ - ---- - _ SAN JOAQUI AL HEA Dl ICT -- - - - - __ - - _ F&S 21677 REV, 7%76 3M ;