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FOR OFFICE USE: �/ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------- ------------------ (Complete in Triplicate) Permit No._ --- oL --------------------------------- -- - ----------------- t Date Issued_1?-9cK_-9 This Permit Expires 1 Year From 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 Or ina e No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC ON1. I ." J = -:_._ ---------------------------------------- --------- --T_--�__-__ .- _-_- CENSIJS TRACT. ------- Owner's Name= ---- on ------------------------- ----- . . . Phone Address 111 , '---- ---------- z � .� Ciry- 2Z zip ''� Contractor s Name---- -- �--- ------ ------ I----- License #__ Phone---------------------------------- y Installation will serve: y Res idence'(�Apartment House ❑ ~Commercial ❑ Trailer Court ❑ i : { Other = iMotel E] '------_' ''---------------- Number of living units:._____��___.__Number of bedrooms__;, ____Garbage Grinder_I_..-._._.__Lot Size -------------- Water Supply: Public System ------name ; t------------------------------ - - __ ....... --------------Private Character of soil to a depth of 3 feet: Sand E] Silt E] Clay E-] Peat0•--'Sandy Loam E] Clay Loam ❑ I lardpan[Adobe ❑ `-Pili MaterialtYp- ----------------- { l (Plot plan, showing size of lot, location of system 'in relati?n to-wells, buildings''etc.'must be placed on reverse side.) NEW INSTALLATION: (No septic tank or'seepage pith permitted if'public,sewer is available within 200 feet) ` , f t r c (I ! PACKAGE TREATMENT' [ ] SEPTIC TANK [ j Size-4__�__.___- __--_;,e�_____________Liquid Depth -----V_____.______.___-_ Capacity--1-�Q-e?---- Type Material • U�'�'�r No. Compartments -- Distance,.to nearest..Well.:___t__-'_�_4_ _ - _-Foundation___�_b_ _--__..Prop. Line----- _ K. LINE N . of Lines.: :..--_ -:_ _- Len`th� of:e1 ;0ac.h,inel-----LEACHING g _. f To_ l Len;; th _ 5��_ � � D' Box- Typeilter Material: ._ Depth:.Filter Materia _. _____________ -_-____------_ ne9Propety Line_ ___Distance,to arest:,Well_ . __-I_0_� Fouhdation__._ _-_ ___._-___. . amee ---_--.---t ° 7� SEEAGE PIT E"J Depth--- __--Nu ____.•-------------------- f r Rock Filled Yes [ No ❑ Water Table Depth }'------,_>__.Rock Size--- - --:-r -�---- F � ` F . Distance to nearest: Well._--__-_ � Fo • __ -- +r ------- REPAIR/ADDITION (Prev. Sanitation Permit#_- -'-------------------- ------------.Date-----------------------------------------I.------ Septic Tank (Specify Requirements)---- ------- - --': -=.----==-----------------------------------------:--------------------------------------------- Disposal Field (Specify Requirements)--------- - ---- = - " ------------------------------------------ - -------------------- ------------------------- -------------------------- ------------------------ - - -- -------------------------- --------------------------------------------------------------{Draw existing and required work will------ --------- - ----�----------'-------- ----------------- ---- - -- Y Y prepared pp I I hereby certify that I have re ared this application and that the iwork will reverse side] i - - II 6e done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Holme owner or licensed-agents signature certifies the following: "I certifythat in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as }� to become subject to Workman's Compensation laws of California." 7 ya - 3 I Signed _.. ------------ Owner — i BYTitle -- --------------------------------- -- ------ (If other than owner) FOR DEPARTM NT USE ONLY , APPLICATION ACCEPTED BY ----_-_-- DATE ----- —=-- -- -..--- _-- DIVISION OF LAND NUMBER---------------------- DATE.---.----.-------------------- ADDITIONALCOMMENTS-- ---- ---- ------------------------------------------------------------------------- -------------------------------------------------- ---------------------------- ------------------------------------------ ---.-------------------------- ---- - ------- ----------------- ---------------------------------------------------------------------- -- ---------------------------------------------------------------------------------------------- -------- = 7T� - --------------------------- ---------------------Final Inspection by ------- == = Date Z EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M