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LUSE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------"- (Complete in,Triplicate) _ a'•"", --_"-- -- -- 1 a? �J This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for and�exsting RK construct Regulations: work herein described. pp This applicrmit ation is made in compliance with County Ordinance a . _ ` -- 1 ---- CENSUS TRACT .------ -------- ------------ JOB �-- JOB ADDRESS/LO TION .-------"----i- Phone-_ r _ r Owner sName__. - - Address_ t a City. Zi�s-- t;, -- -- - - one -' kens L' e # 7l� - Ph - ---------- ------ Contractor's..Name.-_.----- -- s. fes"-' =-----= - - Residence � Apartment House❑ Commercial ❑ Trailer Court ❑ l Installation will serve: ---- Motel ❑ Other = ` -"---Number of bedrooms--- ----Garbage Grinder---___-----Lot.Size------------ ------- Number of,living units:--"- .--- Privdte --------------------------------- - -------- ------------------ ---------------- ------------ Water Supply: Public System andname_---- ------------------------------------------------------- Peat Sandy Loam ❑ Clay Loam ❑ Character of soil to a depth of 3 feet: and ❑ Silt❑ Clay ❑ ❑are �4 r Hdpan dobe ❑ Fill Mafierial_. If yes, type ced on reverse r [Plot plan, showing size of lot, location of system in relation o.fedsVitbulblicse er is avac. must bableawi within 200 feet,�ide.] t NEW INSTALLATION: (No "septic tank or seepage pit p — f Liquid Depth--------------------------- 7Size" ---- SEPTIC TANK Lel' y _� _ I PACKAGE TREATMENT [ ] � No. Compartments--------->--- �� T e l _ Matarial_LJ i Capacity-R-0-0 yl I / - Foundation:./Q------------ Prop. Line-- ------------- a Distance to nearest: Well. f -- r , y /No. of Lines_____17-- --------------- Length of each line.y6---y�,- � Tofial Length..--�- -� ----- - -- i LEACHING LINE- [�}! - S--- ------- -------- r 'D' Box-_' -_-Type Filter Material L - � epth Filter Material"- - _ ---------- ` , r Foundation d --.Property Line._ I Distance,to nearest: Well-J40--o: N Rock Filled Yes ' No -__" _Fou SEEPAGE PlT [G Depth._9_ --__Diameter.-._ �7 ------ --------=-------------- Rock Size---67`---K-3------------------------ r 7 -e- , Water Table Depth-"---- --Q-fQ----- --"---- ------ r i Distance to nearest: We - "----- - •------Foundation..._7cS7---=-- ----.Prop. Line. Date------- ------- -- = 1 REPAIR/ADDITION (Prev. Sanitation erm4 ------ Septic Tank {Specify Requirements "-_"---.-�--------� - -------------- - [^ --- --------------- _- -- ------------------ 8 Disposal Field {Specify Requirements)---------.------- - - - ----- ---------------- ------------- -- L .-----..t ------------------ ----------------------------- -------- k - ----- --------------------------- --. -.r- _ _ _ ---------------------------------- I _____ - ------------------------'--'---,`------`------------------------- ----- ------ --- ------------ -- a ---- " {Draw existing and required addition on reveside) I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin CountyY i Ordinances, State laws; and. Rules 'and Regulations of the San Joaquin Local Health District. Home owner or licensed agents CC .. .. signature certifies the following: 4 "I certify that in she performance of the work for which This permit is issued,.[ shall not employ any person in such manner as to becom su 'ec to W an's Co ensation.laws of.California.'. _ ` - - Owner T -- ----- --------- - ti Signed - 64X-- - ------ ------ - ----- ------- - ------- ------Title_..---- --- - ------ ----- :---- ------ ------ - -- By ' {I'f other than 6wner) r - F�ORDEPARTMENT USE ONLY -------- .. ----- -- --- -DATE.--f----r�" ----- - . APPLICATION ACCEPTED DIVISION OF LANA NUMBER------------ -------------------------------------- ----------------------------- ADDITIONAL COMMENTS--------------------- ------ -- ---- "- - - ---------- ae- EH --------------------- ------- ---- ------ Date f --'-- ---- ----------------------------- ------------- --� - --- -�- --- -- - - ------------- - Final Inspection by*.._,-_------------ F&5 24677 REV. 7/76 3T l3 24 � SAN JOA IN LOCAL HEALTH DISTRICT