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FOR OFFICE USE: - FOR OFFICE USE: P. APPLICATION FOR SANITATION PERMIT ------------------------------------- ---------------- (Complete in Triplicate) Permit No.-..��-�5� I - ------------- ----- --- ------------------------------- S" 7� Date Issued._.__._��_... --------------------- ----------------------------------- This Permit Expires I Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to onstruc and inshe work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS. LOCATION dl____� �� _..- ----- ------X < -----------------------CENSUS TRACT---------- ----------------. .. FF - Owner's Name f + �� ,L ------------------------ ----------------- -Phone__ �:..� , Address..-A-�- '� '. : 1�A1 ��-- --------------------------- City ZiP k ] Contractor's Name... '6_11+ ' -- -----------License # r Phone_ _ate 1 Installation will serve: Residence ; Apartment House.❑ Commercial E] Trailer C urs t [� Motel ❑ Other---- ------------------------------------- Number of iving units:-----.�_-_-___Number of b droam�s__3.__._Gorbage Grinder __---------1 t Size:_..=_-__. :.-___6_.__.-_---_-__-_. Water Supply: Public System and name-.---- \-------- ------- _ _ - Private Character o soil to a depth of 3 feet: ' Sand'R SIJ ❑ Clay,❑ Peat ❑ Sandy 1. ❑ Clay Loam f Hardpan ❑ Adobe [],' Fill.Mdterial1 -____-.If yes,type------- (Plot plan, showing size of lot, location of system in r'bler �t4o weils, buildings, etc. must be placed on reverse side.) " NEW INSTALLATION: (No septic tank or seepage pit •permit�edpublic sewer.is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] tize__ �<__ ' __'____ -----------Liquid Depth.__ __________ Capacity w�LrJ'[) Type pi? �5_rM � ,'= --- ----No. Compartments_ 10� 1 Distance to nearest: Well_,__. 'C2-'-------------------- �Foandat:ior►-._ �__.____ ___Prop. Line._____ ._-. 0�� i LEACHING LINE . [ ] No. of Lines----3______________.. ___.Length of each lined� 1 ___,___1__,.____.Total Length.__, _____.._________-_ fD a 'D' Box_.�j_____-__Type Filter Material -- o �. ep15 Filter Mat rial-----Xf- ______________________----- ` ;...._ - . � nationDistanceto _ x ------------Property Line------____________________ r ; _I Number_______________ _ Rock Filled Yes No SEEPAGE PIT [ ] Depth---- -----------Diameter_;___1__'.__- . - ________ ❑ 1 � i ( . [ Water Table Depth- `---------- ------------ ------------------------------i _. Rpdk Size--------------7---------------------------- ---- j to nearest: Well.-..._'---------I-------------------'.-----Foundatio d---•---------------------.Prop. Line ----_----.----------------- Distance REPAIR/ADDITI . -.Odie_. ---- ---------------'---------------__-) Septic Tank (Specify Requirements)--- ----- ---- ---------- ---------=-----------------=--- ------- ----------------------- --- ---------------- ----------------- Disposal Field (Specify Requirements) --------- -- - - ----- ---- -- 'l`~ `�= --- ------------------ ---------------------------------- --------------------------- ------------------ --------- �-----�------- - --.---.---------------- ---"--------- ----------------- ----------------------------------------------------------------------------------`1` --------------------------:------------= (Draw existing an-d rdquired 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. Holme owner or licensed agents signature certifies the following: of "I certify That in "the performance of the work for which this permit isissued, I shanot employ any person in such manner as to become subject to Workman's Compensation .laws of California.'o Signed � -� -------------- ---------------------------------=----'-------------Owner �0�_the_r_thon BY - ----------'--- - �-- - ---e------------------- --- --i---- --- ---- - =-Title - - ---- --- - ------�` -- ------- ----------.------------ (if owner) ) w FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY____________ _ _ -------DATE.__]___. _- DIVISION OF LAND NUMBER --=------------------------- - ---- DATE_ . ADDITIONALCOMMENTS ----------------------------------------------- ----------------------------------------------------------- ------- ---- ----- I-A - - --------------------- ------- r- ms's - = : " --------------------------------------------------------------------- ----- -- --------------- Final Inspection by=------ - ------- --- -- Date EFF 13.24 SAN JOAQUIN LOCAL HEALTH DISTRICT t/ F&S 21677 REV. 7/76 3M