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FOR,OFFICE USE: - FOR OFFICE USE: APPLICATION FOR�ANITA�'ION PERMIT --------------------------------- --- ---------=--- (Complete in Triplicate) Permit No_______________________ ------------------------------------------------------ 1 - 1 w Date Issued-_-3�: .._-_. .......__ ________________________________________________ 5, This Permit Expires i Year From Date Issued `�oDo o s...icra-ss a. � - _ _ . �,.Gr o----r�":��o mac_-.4...� �'� �- v•- - �7�pplication is hereby made to the SaA Joaquin-Local-Health District-for a permit to construct and,install the work herein described. i This application is made in compliance with County 0.01jaynce ,No-- 549,and_existing Rules and Regulations: JOB ADDRESS/LOCATION --- -` ------------3� C /C� S ' �g�r�4'`- �----�i- C 7 _C d -: L i � -- r L� - - w----------- � � ,--- ENSUS TRACT-- ---- ---- - ---------- --,-..- � Owner's Name'--' �'y� 5d - ------ = ------------------- ---------- ----Phone------------------- ------------------ Address 4J ac�a. 1 ASS c��1f f St -city._.............. P�__n Zip j ------- Contractor'sName_-__--�. ��-'_ -- -- --------------License # -- ----- --------------------------- Installation --- --- - Installation will serve: ResidenceK Apartment House ❑ Commercial ❑ Trailer Court;❑ ' I t Motel ❑ Other_ Number of living units:____.------------Number of bedrooms--- .-'Garbage Grinder _____ "___,Lot Size_________________________________________._______.___.- i # Ie Water Supply: Public System.and name-----------'----.5. �''. �. �'---- ---- ---- -------------------- ----------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand ❑ 'Silt[] Clay ❑ ' Peat ❑ Sandy Loam ❑ Clay Loam X Hardpan ❑ , Adobe'EJ), Fill Material ---- ------If yes, type___- ---------_:__ (Plot plan, showing size of lot,--location of system[in relation to wells,buildings, etc. must be placed on reverse side.) Q NEW INSTALLATION: f(No.septic tank or seepage pit permitted.if public sewer is available withG 200 feet,) PACKAGE TREATMENT [ ] . SEPTIC TANK' ['] Size------ -----------------------------------------------------Liquid Depth--------- .--- --� - ; Capacity T e Material-------6I' - No' Co -- C�sT Cerv[_ R mpartment ___.__a / C�Co `° P i Distance to nearest: Well'--------------------.------- -- Foundation_-:__!O.-._'., Prop. Line... .-`- I , ' 3 ` No. of Lines.�+'�`�_rX -Q_------Length of each lina-------------------------------Total _Length-_---------------------------- Y"^r :D' Box -Type Filter Material._13C1'._____Depth Filter Material---------b ------------ ------------- --- Distance to nearest: Wel! __,__-__Foundation - Property Line-------------------------- SEEPAGE -_______'_ _ _________ Diameter..---- ` Number_ -__-_ Rock Filled 'Yes SEEPAGE PIT [ ] Depth = ❑ `, ❑ [ Water Talale Depth----------- ---= -- ` ------Rock Size----- ----------------:------------------- ---- • j Distance to nearest: Well-°---------------------- Foundation--------- ------------ Prop. Line--'_-------------------- --- E REPAIR/ADDITION-(Prev. Sanitation Permit#------------_------------------------------------------Date-----=----:----------- _-• ------------------- _----•---_---------------------------------------------------------------------- ------------- -)--- ---- FSeptic Tank (Specify-Requirements}__- ----------- Disposal __.__- Dis osal Field(Specify Re uirements)___ ________ - ----_� --��- - 'm ,. -------"--------- ------------------------------------- = - -------- --- --------------- (Draw existing and required addition on reverse side) Q t I hereby certify that I have prepared t�iis'application and that the work will be' done in accordance with San 'Joaquin ounty Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: q "I certify that in the performance of the-work for which this permit'is issued, itshall 'not employ any person in such manner as to become subject to Workman's .Campensation,,Jaws of California.'.' _ .t F r E Signed- ---- ---41v 7-4 __ _�;-fly--------- - --- -------Owner - - ---- - Title � - other't an owner} r F R DEPA MINT lJ5 ONLY APPLICATION ACCEPTED'-BY-.--- _ — DATE - � ----------- DIV[SION OF LAND NUMBER. f - ----------------------------------------------------DATE------ ---- - ----- ----- ------------ -: ADDITIONALCOMMENTS----------------=- -------------- ------ -------------------- -•-------------------------------------------------- ------------------------- . ------ -.- ------,---- ,----- --------------------------- - - ----------- --•------ --- ---------------------------- ---------- --- --------- --- --------------------------------------------------- i ---------------- -------------- ----------------------- ------------ - +- s _ --------- ----------------------- 2!_ �"� _ Final Inspection,by. Hate: EH 13 24 S: N JOAQUIN LOCAL HEALTH D.ICT / F&5 21677 REV. 7/76 3M 4