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FOR OFFICE USE: /�/ f FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------- ----------------------- . i Permit No,2%f,� _f_ (Complete in Triplicate) ----------------------------------- -------------- Date IssuedfO_-34?: ------------------------------------------------------__ This Permit Expires I Year From Date Issued t � 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/LOCAT ON___.-Q___1--0- — --------- "'C'"---/ -/7`-�!_--- . .CENSUS TRACT------------------------------. �, �y � Owner's Name. /'`1"C/ "--- _ ' ------------ - -- q o . Phone _ V / . .._ - City ._... P---------- -------------- Address Contractor's Name- ---------------- _ e' +1� _ ,d�r✓ts<. a License # _ �.7-- ---Phone_ ; Installation will serve: Residence'K Apartment House Commercial Trailer Court ❑ { t P ❑ ❑ I-; Motel -��--_ Number of Iiving.units ._ -------Number of bedrooms._ _._Gageer_-- Lot Size_.= ------ ;,e _ --------------- i.- Water Supply: Public System.and name---- r _:. __. _. _______ Priya m� Character of soil to a depth of 3 feet: Sdnd n =Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ ; ' Hardpan ❑ Adobe '' Fill Material------------ yes, type________________.___.__..___- e 4 (Plot plan, showing 'size f lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: I(No septic tank or seepage pit permi4te if public sewer is available Liquid Depth_ within 200 feet,) th.__- ) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Cl'-S 7V, _.___ "-__- �lL_r -- f-- q P k Capacity = _TYPe-----------------------Material_.------------------------No. Compartments------------------------ � V3. 'Distance to nearest: Well .---------------------------- Foundation---------------_----------Prep. Line-------'---- y � � LEACHING LINE No. of Lines---,______'_______ __Length of each line_ _ ___--------------total Length _____ lr r'D' Box--:------ -Type Filter Material------- ------------Depth Filter Material----------------------------------------- -- --- Distance to nearest: Well.:_'a1=4V_______________Foundation____ -�-_ _. _---.ProperV Line--_-S -- _-x------ } I --Number- -- �""�. Rock'FiIW YesA No❑ SEEPAGE PIT Depth�s,�`'� Diameter -----=- -----l----------- - ---- ------.Rock Sii ----" ` -------------'-�----=�--- �� l i -- f Water Table Depth___;__-_ ' Distance to nearest: Well.'_ ' �......Foundation-----l*J_-------:__.Prop, Line----->L5___-________E___ REPAIR/ADDITION (Prey:Sanitation Permit#_k-__-------- _-- ff7� ----------------'Date__________.____..______- {----- -----) r � � Septic Tank (SpecifyRequirements)--=------- ---- ;� ----------- ----------- ----------------------------- L ---- ---- -------- - - Disposal Field [S ecify Requirements re, `' f----- ---------- --------- --- -------- . t', c t ------------------ �''== --------------- -------------------------------- - -- ----- ------------------------------- ----------------------------------------- - - � (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 csccordance with San Joaquin County Ordinances, State Laws' and Rules and Regulations 6f 1he'San Joaquin Local Health District,-Home owner or licensed agents signature certifies the following:�f "I certify that in the performance ofrthe work for which this permit is issued,,] shall not employ any person in such manner as to 'become subject to Workman's Compensation laws of California." Signed f - �: 1 _"p^ner4 C � S � � fSERVICE.-- ------ -- -- �P � cnCat952�5a Title - 23So0►4_ 5j .BY Ph_463-3209 Contractor's Lic.#26X77 (If other than own r ! f FOR DEPARTMENT-USE ONLY APPLICATION ACCEPTED BY_:___ _ _._ -------------- DIVISION OF LAND NUMBER. r - ' ------- ------------------------------- ------DATE.--- .---- ------ ------------ ---------- ADDITIONALCOMMENTS----- ---------= .' -' ---------------------------------------- ---. :.r :--- ----------- ----------------- ------------ 4 y1 d Fina! Inspection by:- ---- 7'=- ---- ate -- ------ EH — .. EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 son