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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ______ 77 : -- Permit No _____ $ ` ----------------------- (Complete in Triplicate) Date Issue7 d._ ---�----�- -�/ .� This Permit Expires 1 Year From Date issued truct and install the work herein described. Application is hereby made to the on Joaquin fy`k HealahriDeSNo}549 anor d exist ng Rules a d Regulations This application is made in camp �1 $� -- -- --- ------- -- -- ------- ----- ------ ----- . CENSUS TRACT. JOB ADDRESS/LOCATION Poe ----- --------------------- ------- ---------- Owner's - - -- . _ Phone Owner's Name. -- - _ . --{-- --------- Zip --- Address------ C 0_- ,. /�y �3 License Phone v� I -7- 17 Contractors Name__ - Installation will serve: Residence F1Apartment House.❑ Commercial Trailer Court El ... Moteh, ❑ . Other .._ = — ----- Garbage.Grinder._. .__ '- Lot Size_ ---=- -_- -- _ t . Number of living units:___------ _ - - Private ❑ Water Supply: Public System and name------------------ ---- ----- # _ Num er o bedrooms. i Silt ClayPeat Sandy Loam ❑ 'Clay Loam ❑ t Hard an ❑ ❑ O ❑ I Adobe Fill Material- - ' If yes;type T Character of soil to a depth of 3 feet: Sand ❑ ,( p t {Plot plan, showing size of lot, location of system in relation to wells, buildings,etc. must be placed on reverse side.] t p g p P if public sewer islavailable within 200 feet,) i NEW INSTALLATION:` (No septic;tank`or see a e it ermined _-Liquid Dep#li_-------------------------------- E ______________ ___ ___ �. ---- SEPTIC TANK [ l Size----------------- ----------------�-------- PACKAGE TREATMENT [ ] +� Mat®vial-- ----------------- ----No. Compartments----------------------------------- t Capacity---'------------=----TYPe-----_--------------. _._-_-Foundation._>- ------- ---------Prop. Line to nearest: Well--- = �S y Distance F I . i LEACHING LINE I :] -No._of:Lin�s.._-�.�--_----__--�=-.Length-gfeach-•line.-----------=-----'----_----7otal Length __ .------- ,-------.--:---------------- p Material = --------- Depth Filter Material------------ ---------- - - .------- _ P i --------=-------------s Distance.to.nearest: Well -----y - ; D' Box.____.-__ Type Filter { '`�' ''. � � k ` Foundation-- Line- = --- N .: t .... .;... .. - Rae ..i. ..t.. . ... Yes ❑ o'❑� k Filled SEEPAGE PIT [ ] Depth ` �.Diameter. ------- ----Number-- ' F ,.... : _ Roc iz - ----------- Water Table Depth------------------------=---------- k Size'- - . e' Foundation- ------------------------Prop. Line Distance.to nearest: Well^i • ADate--------------------------------------------- REPAIR/ADDITION (Prev. Sanitation Permit#-- ---. =--;- Septic Tank (Specify Requirements)_____'............._- ---.- --- ------=----=--------------- - ------ --- ------ ------- - ----------------- Disposal Field (Specify Requirements)---------------------- -------------------------------- ------------------- --------- ------------------------ r_ lot�------ - ni ---------- -------- ------------- -------- a. (Draw existing and required addition on reverse side) Son quin , ance with I hereby certify that1 have prepared.this application and that the work will be done Dist icf. Horne wnerr orlicensedns d agents Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Heai signature certifies the following: r "i certify that in the performance bf.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." i _Owner ; Signed ------ ------------- -------------- --- - itle -- T F .. - -- n I --- + (If other than*owner) - FOR DEPARTMENT USE ONLY " - DATE = = ------- ------------- --------------APPLICATION ACCEPTED BY------ ------------------------ ------------ DIV1510N OF LAND-NUMBER -- ADDITIONAL COMMENTS.----------1-- ---------------- ----------- --------- --------------------------- - ------------- ------ -------- ---------- ------------ --------- - ---- ------------------ -- ---------------------- Inspection b -- ------ ------------------------ - Final Ins y. -------------- ------------ -- �-------------------------------- ----------------------- ... Date-_ - rF&S 21677 REV. 7/76 3 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT