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FOR OFFICE USE: "} ppll A I FOR OFFICE USE- APPLICATION SE: A C TION FOR SANITATION PERMIT ------ ----------ow- -- 11., %� , Permit No---7 l/ (Complete.in .Triplicate). • 4. 't*, { _ '4 Date Issued.. . ---- --- --------- ------------------------ ------ --------- ----- .��_-____.� This Permit Expires 1 Year From Date Issued +4 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: JOB ADDRESS/ LOCATION_____ _____ 5___-_--- Q= -- ---.CENSUS.TRACT------ - -- -- _0 = Owner'sName •------1--- Phone'. ? �` Address-C�® 5 =City -- ------ - --------------Zip------------------- -. ----- Contractor's Namtt e-----_-_- [! __--_ 'License #-a 7,rJ-��____-Phone__` __._S=__._._- - �___- Installation will (serve:- `. A Residence' Apartment House ❑ -Commercial ❑ sTrailer Court ❑ r Motel,❑ .- Other- ----------------------- : Number.of living units: _ ---------Nu rn"ber.of bedrooms _;_.__Garbage Grinder. .__._____Lot Size-__'1 _________ ---------- Water Supply!; blit System and name ------ - .__.__.w _ '-------------------------------- _ - -------------------- ------Private( Character of soil to a depth of 3 feet Sand ❑ kSilt❑ Clay ❑ Peat❑ Sandy Loam E] Clay Loam ❑ , t Hard pari❑ i Adobe Fill Materia l_.._.____.._lf yes, type________________________________ ' (Piot plan, show'ng size of,lot, location of system in relation to.wells, buildings, etc. must be placed on reverse side.) �. NEW INSTALLATION.:_-(No,sepric„tank..or seepage pit perrmited if public sewer.is available within 200 feet,) PACKAGE TREATMENT [..] -SEPTICTANK 1 Size-----=---------- - ` --Depth -------------- -------4- --- . _____ Liquid tA CapacityTYPe----- - No. Campartme -Materiants i . .. . Distance.to nearest: Well :.__.. Foundation------ - - ------- ---Prop. Line---------__._------------ LEACHING - -_ -- LEACHING LINE. [i] No. of Lines..N---------------- Length of each,lins----------------------------- .Total Length---------------------------------------- Box--:----- _._.___. _ ._x __.___[__Type Filter Material--------------------Depth Filter Material t Distan - -� ., _ p,r ca to nearest: Well = [ Foundation. - Property Line- ' SEEPAGE PIT C' l Depth-----------'----Diameter---------------------Number-----------------'•----_--------_ . Rock Filled Yes.❑ No.❑ Water Table'.Depth.__'-----_ -- Rock Size ?fir � Y I � L � �•� - � : s� ,}�,.,. --------------------------------- _ l Distance.to_nedre'st:Well " _ - F6undati.on__`__` `---------Prop. Line ;�� ] REPAIR/ADDITION (Piev.aSanitation Permit#--= -- ---- .------------- :------,Date------ ----------- Septic - --------- ) ` t 1 a = ------------- ��-]- i '-.r • [ Septic Tank (Specify Requirements)_--..'�-.-__-_ - _ •�• - •�-� � � ------------ -- -- - Disposal'Field.(Specify Requirements) - �-== -- ----------- ----------- ----- ��° --- ---------------------------------- - ------------- - = --- ----- --------------- -------------------------------------------------------- --- --= ---- .------- -: --------------------------- - ----- ---- ----- - ----------- (Draw existing and required addition on reverse side) I hereby certify that-1 have prepared ,this application and that the :work will be done Lin accordance with San JeaduinCour•,t;+..--- � 'Ordinances, State Laws, and Rules.and Regulations of the San Joaquin Local Health District, Home owner or licensed_ agents f signature certifies the following: "Icertify that in the performance of the work for-which this permit is issued, I shall not employ any person in such manner as to become -ect to mans Compensation laws.-of. California." Signed-- -- -�`�-(_�- --=w_-1 :--------Owner BY - ---2a--An` ------------- - ---- ---- - - Title [If other than:o'wner} 1- FOR DEPARTMENT USE ONLY 4 •' ; APPLICATION ACCEPTED BY--- --- --- ------ DIVISION OF LAND NUMBER._ -------------------- - DATE P ADDITIONAL COMMENTS__ 1sf I�------------------------------------ - -- ---- - ------------- - - - -------------------- ------------------------------------ ---- -------- -- ------.-- ------ ---------- _--.-.---�--�----�-: = = = _. = :-_ = _ ----- ---DateInspectron by:----- EH y ` EH _ 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M ! s