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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: {Complete in Triplicate) Permit No.7.9'-�0------ -------------------------------------------------- a 41 e r� q --"----"-------"----_._ This Permit Expires Year From Date Issued Date Issued-7_-16._' b Application is hereby made to the SanJoa uin Local This application is made in compliance with County Oregnanclth e Nott 9 and xis#ing Rulermit to rs nan install the work herein described, �-- .._. ,..... , . „ . -.1. s. JOB ADDRESS/-LOCATION---S --- - -- i Owrner's NameUS TRACT = ------------ :: - = Address -.:: k e-------------------- ---------------- -------- -- ------ I ---------------Phone - Contractor's Name----- ---- P � _ ` - _-.:License #_ - . Installation will serve: '_ 3 Residence Apartme t House ❑ 'Commercial Phone 0 .. * Motel .-., T ❑ raifer Court ❑ ❑ , Other---=-- =----- -- ---- ---.-- �----- --- 1 - r Number of living units;__ I--_-._--Number of bedrooms_`_-3__.Garbage Grinder------_..,_-Lot Size____"_.,._._t Water Supply: Public Sysand name------------ ------------- "---- - ------------------ temPP Y -- -- .- - r r Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay❑ pe _ i-=----- ------- --- ---- Private j Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan 1 Adobe ❑ Fill Material-- "-Vis."-- Ifes Y , type ---------------------------- (Plat plan, showing size of lot, location of system in relation to wells, buildings, etc• must be placed on reverse side•) NEW INSTALLATION: (No septic tank-or seepgge-pit permitted'if public sewer is available within 200 feet,) PACKAGE TREATMENT ( •] '-'SEPTIC TANK [1] - _ r m ---Liquid Depth.,._ th .�..- ------------------- "Size ------_-tt _ -" S Capacity . TYPe ` = --Material alCompartments---�-----Distance.to nearest:.Well.:. '- • --------------------- O(� i Foundation-.-=--------------------._..Prop.' Line.`---- _1 LEACHING LINELines-'' [ 1 No. of - ,-----------. Length of each line. Total Length_-__ i . ,.. ------ tj Box-..-.----,_-Type Filter Material-__-_-- Depth Filter Material------------------ Distance to nearest: Wel! Foundation _ ------------. ,.._ .......Property'Line._n _ SEEPAGE PIT j ] Depth--..; Diameter.. _ --�, Nu Number , __ Ck -- -- Rock l e N r Water Table:Depth--------- --- Rock ------------ _ Fi e�d Yes ❑ - o' Distonce;'to"nedrest:-Well - _;. _ 1 Foundation._ ------ ------------------ --=-- -----.Prop. Line REPAIR/ADDITION (Prev. Sarritation'Permi.t'#__ _______'- - ---,Date--- -------=------ ' Septic Tank (Specify Requirements)___.__.--_._ Disposal Field (Specify,Requirements)___ """ " ------------- ------------------------------- y -----_------------- - ----- ----- ----- ------------------------ -------------=------------------------, (Draw ezisting'and required addition on reverse side) hereby certify that-I have prepared this application and that the work will be done in-accordance with Sara Joaquin County Ordinances," State Laws, M1and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents � signature certifies the following: i "I certify that in the peiformarite of:the}work for which this permit is issued, I shall not . 1 to become subject .to Workman's Compensation .lpws of -California." fs1h nner as � Nrs Signed- ----------- --.. _ By--------------------- = Title 13 ; ------ ------------- ----- -- -- Owner It e - --` [lf other than : .. - 197-------- owner) FOR DEPARTMENT USE ONLY ' SAN JOAQUIN LOCAL APPLICATION ACCEPTED BY ---- r ---- --- -- DATE.---- ----- -------------------- ADDITIONAL -- DIVISION OF LAND NUMBER.-----`------------- -- - --- -------- - - -------- -- -- •' --------------- --- = ---------- -DATE------- -- - ----- ADDITIONAL COMMENTS-- `_ + --- - -- = b �r„ * A------------------------------------------------- - ... -------- # ----- ------ ------- ------------- --------------------- - _ Final Inspection b - -L---,Date -------- - ---- - -------- k -------------------------- EH 13 24 Y _ - - Date_=�_'_-�-��- � -/�y� SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M