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�.y k ` FOR OFFICE USE: APPLICATION FOR SANITATION PERMITFOR OFFICE USE: --------------------------------- I/4vVL 7 Permit No.- ------ -- (Complete in Triplicate) Ow 140 �J 7� div <5�10l4 e Issued---------------- ------------------------- -----f -- -- .--• ------------------------------ This Permit Expires t 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 ma �i compliance with County Ordinance No. 5249 and existing Rules and Regulations: JOB DRE S/LOCATION- - - - ----------------------------------------_q q --- CENSUS TRACT F �/f¢�t[ Si Gf -le - - -------------Phone� - --.� --2,- ---- Owner's Name-..�-.. ---------.. 3 0� CSP v� _ Ci r � LaN. Zip �`� -a"--�-- ---- Address----- ------------ -- - - --------_ ------------- city Contractor's Name__QG✓ICI, '----- ---------------------- -------- -------License # -------- ----- --------Phone.--------------------- ------- --- Installation will' serve:" Re Clence•❑ Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel.❑'��i Other-- --------- i ------ Number of living uriit': _ ----Number of bedrooms-_-.-Garbage Grinder---.-_-----Lot.Size.--.-- --- -•�-----�---- ------- Water Supply: Public System and name-. - J---.----------------------- --- =- _------------------------ -- ------------------.-- ------Private El Character of.sod'fo a depth.of 3 feet: Sand ❑ Silt❑' Clay o Peat❑ 'Sandy Loam Clay Loam ❑ Hardpan Adobe.0 Fill-Material--_---- .--If yes, type-------------------------------- (Plot plan, showing size of lot, location of system inrelation toywells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: {No septic tank -or seepage pit permitted if public sewer is available within 200-eet,) �-,� . , - r x {Size----- Z Q--` a_4_4 — Liquid)Depth. t .-..1I �p - PACKAGE TREATMENT cap Type("n-------._-.--TMatevial.-_-C_71�C,------.No. Compartments - _---- --- �r Distance to Weare t: Well � ��rya � == 'Foundation:-___ ---7`-.,-_PropLine_:-----------?' - -----. 7z 0 LEACHING LINE [ ) No. of Lines------ _Z-___-Length of each line.-.___ -?0---.Total length -� I -------- I f �C O� = 'D' Box- <-----Type Filter Material(----Z- --?-�e�h"Fifter Material----19 --- ---`----------------- ---------------------- > �2) qd T }��0,4istanceto nearest: Well-4.00------�.-----Foundation----------------------------.Property Lyne:----------------------------------- 7-4 ----- -----------------------. SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No ❑ WaterTable Depth----------------------------------------------------'-: -Rock Size---------------------------- ` -- ------- Distance.to nearest:-Well- ----------- -Foundation--------- ----------------P op. Line / REPAIR/ADDITION (Prev. Sanitation Permit#---_--------------------------------------- -------Date--------------------------------- ----1 a jr Septic Tank [Specify Requirements] - ---° --=-------------------------- --- ---------------------------------------------------------------------- Disposal Field(Specify Require ents)--=.-.---------- - --- ------------ ------ -,!�------� ------ 71 ----- --- ! ..- C ` -tea ---- �-------- ----------------------- ------------------------------ --- -------------- , 1 -------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will -be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "I certify that in the perfoi^mance of the work for which this permit is issued, I shall not employ any person in such manner as to become s b[ect to Workman Compe ation laws of California." a Si Wed .-- `r g T Owner By-`-------------- --------Title-------- - ---- --------- (If other than owner) ( FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ---- --------------- - DATE. A- s ( f -- -------------- ---------------- ---- PDIVISION OF LAND NUMBER----- ---------------- ------------- -------:---- - ------ ----------_---DATE.------------ ---------------- rADDITIONAL COMMENTS---------- - -------------------------------------------------------------- ;---------- - ----------------------------- --------------------------------------------- - -------------------------------- - ------------------- ------------------------- ----------------------- ------ -- n - ` — Final Inspection bY: Wil/ Date y EH S3 24. SAN JOA IN LOCAL HEALTH DISTRICT Fa 21b77 REV. 7/76 3M . I .. W - 0