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FOR OFFICE USE: FOR OFFICE USE: 2_'_0_0 APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No..__ ._____---.-------- --------------------------------------------------------- ------ _- This Permit Expires 1 Year From Date Issued Date Issued-./ Application is hereby made to the San 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/LOCATION_.-�. -�------------- �f� �- " - Z""`--'T'-1'�---------------- ----------� -CENSUS TRACT------ ---- ---- -------- ------- Owner's Name------------- �------------ ------ -„ - Phone- i�0 1 l-_7 L7 i Address__.__:.-._-._. .. 0 ' ✓"_ City----- - -- --------------Zip---------------------- - Contractor's Name_.•_. __ ______. __ ---f-- --- - -- - y 4 .license #� `3` 3------Phone----�f��a- Installation wwill serve: Rest en- Apartment House.❑__-'Commercipl E Trailer Court, ❑ E E / T.. _N �• • Motel Other------ Number of.living units::-`1_-'LJ! -.__ umber of bedrooms` f- - .-- --_.--Garbage Grinder-'--_-_ __Lot.Size___.__ 1. �. T.— . .� Water Supply: Public System_and name =----- -------=--------------------- -- ---------------- ----i------------------------------------Private ❑ d s Character of soil to a depth of 3 feet: Sand ❑ :Silt Q Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ ' r _.. Hardpan ❑t jAdobe$' Fill Material___-- ___...If ye's, tyPe--------- : [ (Plot plan, showing size of`lbt,location7.of`system in relation to wells, buildings, etc.,must be placed on reverse side.) NEW INSTALLATION: (No septic tank 'or=seepage;pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT Ga acitPT1C TANK ,(7_]_V, aid Size ----------------------------- Liquid Depth--------------------------- .� P y-- = = YPe -----------------------Material = '-No. Compartments Distance to nearest: Well--------------------------------- -------Fovndafiion___-,� --.-_.--.Prop. Line----------------------____-. INE [ ] No. of Lines ;` _ th of e.achrline` Total;Length - D' Box__------- --T . Fi1 e ' trial --~ 9 � I s + � Type # r Ma e a _.�" nr7Depth Filter Material----------- ---------------- - --_ ------ - --•---_-- t - 1 Distance•to nearest: tilt.------------------------- ouInd ation------- ----_-___-------__-Property Line----------------_. __-. [ ] De Depth -------._Diameter.`-----------------.-N.umb . # .� .-.. ....... . .. _. _ SEEPAGE PIT pNumber___ ------------ ----.....______ � Rock Filled =Yes ❑ No - Water Table;Depth---�_----- = _ "r'Rock�Size -------- Distance'to nearest: Well. "_'.._:_----- -.: Foundation ' - - Prop. Line-------------------------- REPAIR/ADDITION (Prev. Sanitation Per y'i.t,# `_ '--------------------__`_.___�Date_p------------------------ -------------- ---} Septic Tank (Specify Requirements)---- -- -- ---- - _ �- ---` t' ---- r:-�uv f--,aF - s --- --=--- Disposal Field (Specify Requirements):--- -------- -[ = ------------- --------------- � f -: . e ------------------------'---------=--------------- � � i existing and(required-adclitiorF,on reverse•`side)j, 4 I hereby certify that I have prepared this cipphcation and-that-the=work will be�done in accordance-with San Joaquin County Ordinances,- State Laws; and=Rules=and-Regulotions--of..-the-San-Jo'aquin focal_ Health District. Home owner or licensed agents signature certifies the following: i { I "I certify that in the performance of fhe work for-which this permit is issued, 1 shall not employ any person in such manner as I to become subject to Workman's Compensation laws of California." i Signed--.- --- ------ --------------------------- -----------------------Owner _ By------------ -----, - ------------------------------Title------------ ------ - ------------ I {/-- -----. ----------- . ' t (If other than owner} t i FO DEPARTMENT'USE ONLY i APPLICATION ACCEPTED BY _ --------------------------- DATE. f -------------------------- ------ DIVISION OF LAND NUMBER ---- ----- - ` ' =' DATE --- ------------------------- ----------- -----------= ADDITIONAL COMMENTS-------------------- ----------------- - --t f- ------------------------- -- - --------------------------- - --6------:-------------------------------------------------------------------------- ----- --- ------ --- --------------=------=------ ---- --------- --------------------------------------------------------- ----------------------.------ ------'-------------------------------------- ---- ------ --- ----------------------------------------------------------------------------------- -- - i Final Inspection by:..-" /._ _ - ��- � ---- ?--- -- -- _- --°-- - - ------------------------------------------------------ ------ ----Date.----�- - i fH 13 24 S N JOAQUIN LOCAL HEALTH DISTRICT res 21677 Rev. 7176 3m