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it ;..FOR OFFICE USE: kZ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------- ---------------- (Complete in Triplicate) Permit No..7 _Y -_-3� ---- ------------------------------------------------�---- bate Issued�O_a�_-�8� _ This Permit Ezpires�l Year From Date Issued � . A Application is hereby, made t18-the.Sa�1�J�o quin Local He`gqi1th-district for a permit to construct and install the work herein described. This application is ade in corriplionce with County Ordihance No. 549 and existing Rules and Regulations. JOB ADDRESS/LO& TI r --- F ---.CENSUS TRACT --_ --- ---- -- Owner's Name , � a = ' ------ - ----- Phone Address_ `` , ' -- ------- - - L _7., VQ\ City ip Contractor's ame.; -- i --. -- -----------------__._. Y Iscen e # -5- �J-T -----Phone---Tim_ --- ----- Installation'will: serve: Residehce Apartment House ❑ Corrimerrial ❑ 'Trailer Court. ❑ s . .� .Motel Fl. Other ,� , Number of living units:__.._ '__Number f b"edroonis = _i .Garbage Grinder ------------Lot Size_ _____ _. Water Supply- Public System;anclnamewx.�..�� _- -- -- -------------------- -- -------.Private Character of soil to a depth of,3_feet -ea- ❑ Silt❑ CIa TPeat❑ Sandy Loam T _Clay Loam i s - ...tet, Hardpan ❑ Adobe ® ill Material-..-:;_,__.._I Yeses,tyPe---------------- --_----- ] {Plot plan, showing size of lot, lacatio}}n of system . elationryao wells, b�ild�rigs, etc-"must be.placed on reverse side.) NEW INSTALLATION: [No septic ttrnk or"seepage .pit permitted if public sewer is available within 200 feet, '�ANK""]`].�._ .�_b_ _Size-----=-------� . ------------------�iquid Depth---------------------- --� PACKAGE TREATMENT EPTICCac _M'aterial___ ________ ___ •- No. Co: artments-- ___-_____------------------ a P ty-:---- ---'-----------Type.:---------- ---- p Distanca_..to nearest: Well-'--------------- -------- ----- - ---Foundation.'.. -. Prop: Line I c ' ;< LEACHING LINE. [-,] No. of:Lines_j- k..: _"L ngih „eFh line F� Total Length a 'D' Box-_1---- --Type Filter Material--------------------Depth Filter Material---> - --- -Foundation--- ----------- -----=---Pro elr -(Line----------------------------------- PIT ------------------ I Distance to nearest: Well------------------------------ -- -- SEEPAGE PIT [ ] 'Depth: _ Diameter ____.._E--. Number __- -_ _ Rock Filled Yes.[] No ❑ 1Nater TablesDepth. - :. --------- Rock .Size:----- -- Distance to nearest: WeIL--------------- -:------'-----:------.Foundatio ---------------- --- - } Prop. Line--..-- r---. DITION {Prev. Sanitation-Permit-#:.�.----'"----- ------- ------Date. :----_'--::------:------------------ --- REPAIR/AD Sep (Specify q. i , . tic Tank {S ecif Requirements)-.--.-'-----....,-..-- =- -- - --- ---------------------------- �;�= = } � Dis osal Field (Specify Re uire _ . p p Y q mentsl � ------------------------------- , -- -- --- - - - III' f_? � ��"Cela � ---- ---------- ------------------ I"� � 1 �Y' '+• r - Gip -------------------------- " �� --------- --------------------------------------- (Draw exisX.ing-and-required,-pddi#ion on reverse sided hereby certify that-I�have prepared-hiesapp it cation and that the work will be done -in-accordance with San Joaquin County' Ordinances, State Laws, and Rules and Regulations of the Sar; Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "I certify that in'the perfornidnce'of'the work for which this permit is issued,'I' shall not employ any person in such manner as : to become subject to Workman's Compensation laws of California." Signed_;.. . . .. -- ,Owner r .. ., -4 - % f' , B f -------------------------- _ 1;1 i , isle ' (If other than'lowner) �w FOR DEPARTMENT USE ONLY r " APPLICATION ACCEPTED. By... - ------------ ----DATE 4, - ------ - DATE------- DIVISION OF LAND NUMBER-------------- l ADDITIONALCOMMENTS-------- -`- ----=---------------------------=-------------=------=------------•------ ------------------ ----- ------------------------ ------------•--------- .......------ i ---- ------------------------ -------------------- --------------------------------------- ----- ------------- - = -- --- -- - I r ----------------------------------------------- ---= - --- ----------------s ---- ------------=------------- -- -----------------------=------------------ ----- -----------=------------------------------------- -- - --------- --- - - ---------- - -- --- - -----------=------------------- ----------- --------------------- ------- -- -- ---- ------- --------------- I------ Date.Inspection ------------ = EH s 24 SANJOAQU OCAL , HEALTH DISTRICT Fas 21677 REV. 7176,3M ii .��