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FOR OFFICE USE: r APPLICATION FOR SANITATION PERMIT FOR OFFICE USE.o.- t 4•-.,.._{COM01et rr Tiipl a#e} Permit �� 7 ------------------ --- ---- \IX T - . r�•.i�t,N 7 . --- - --- This Permit Expires'l Year From Date Issued Date Issued .._._�__-_----_- Application is hereby made tothe San Joaquin Local Health District for a permit to construct and,install the work herein described- .1, This application is made in copliance with County Q dinance No. 5and existing Rules and Regulations: 47— JOBFADDRESS/LO I. N ® - ---'7'---_--- P►��G� CENSUS TRACT { i ----------- Owner's Name._ Ad _ = ._. . .: -:----- Phone--------- dress---- __ k ----- Ci '------- d' 4 __ Contractor's Name------- - [ ` / License _., i r #O� l - .__Phone_. _ ___•_�_ ------------- } Installation will serve: Residences Apartment House.❑ Commercial ,Trailer Court ❑ y ,._ Motel ❑ Other_.:_ Number of living units:..:t,� Nunrber of bedroo Garb ' age rr�ader .,._ aLo##5ize------------ -- // ll Water Supply: Public System and name Gt/�' --- , ------- A GG - _. - I . � ------- -- ----------- ------------Private ❑�� Character of soil to a depth of 3 feet: Sand ❑ Silt 0 jClay ❑ Peat❑ Sandy Lo�m Clay Loam ❑ � F Hardpan ❑ Adobe i Fill Material___._;------If yes, type-"-------- ------I----------t ; (Plot plan, showing size of lot, location of system in relation to, relis, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No se tic tank. or seepage [ '• i - IIPpit permitted-if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [,] ;— + ' S1ie____ '� ___ ---- --- � --_� Liquid Depth..... Capacity = = Tse.---------`_6:__-- "= I l� YP -------No. Compartments------ ------------------------ Distance to nearest.Weld ----------- Foundation------------- ------------Prop. Line--------------- ---------- N LEACHING LINE [ ] o. ofj�Lines-;•_:--------- 9 :. -.-----:Length.of each Iine-.: '-. - -----Tota l Length.r------------ --- I YP FtY .M_ ate-rial;-_-------------F__--Depth Filter Material----r j-----------.- --- -- -- -- ----- ------ DistanGeto nearest Well - Foundation F__.. - ProPertyLine ----------------------- SEEPAGE PIT Oepth.. __ _ '_-_-DiameteP, ` Number ---------- e Rock N ❑ Water.�I able Depth--------►---- Rock Size! _ - � -.:.;�-- - _ „-.. . - Yes.❑ o [ i -----Foundation ----------- .Prop. Line_ REPAIR/ADDITION Prev. Sanitation•Permit#:.? . '` - (stance to nearest: Well--.--__._ -- --------•------_---- ' - "Date `. . -- ' ------------- Septic Tank (Specify Requ'i ) bis'posal Field (Specify Requirements)-- __ -- -------------------------- ,_ ---- ---- --------------------- ---- -- I 1-: L ---------------------------------- - - .t.. __________________________________________________________.---.---"--_-----.:--------`---"------- "--------------------•------.-- --.- (Draw existing and iequired addition on reverse-side) I hereby certify that.11 have preps red this application and that the work will be one m accordance with San Joaquin County Ordinances,. State Laws, and Rules and Regulations of the San Joaquin Local-Heal�h District• Home owner or licensed agents signature certifies the follow" 11 : • T t g: "I certify that in the performari ie of the.work fol which this permit is issued, I shall not employ any person in such manner as to become sub" to arkman's mpensi tion laws of California." C ib L Signed-------------- --- i s 1 a v ne BY .-- ------ _ ---- t fig .-------------------------------------- (If other�tPhoner - d } [' FOR DEPARTMENT USE ONLY- APPLICATION ACCEPTED BY i '..DATE._- /.-7 7 ---- DIVISION OF LAND NUMBER.----�F�j-_ [ --- DATE.-----------------_ ADDITIONAL COMMENTS--------- I� - - ''t t -------------------------------- ik �r ----------k" -----------,; - ----------------------------- --------------------- _ ---------------------------------------- ______________________i_...h 1~n__--i--.---._�-----_-" ----.-_----_-._--_ Final Inspection by* - a-Date. J-fir= - ex 13 sa SAN JOAQUIN LOCAL HEALTH DISTRICT �� F&S 21677 REV. 7/76 3M i Y �